Every finding on record at Royal Gardens Healthcare

Based on observation, interview, and record review, the facility failed to maintain and provide a safe and comfortable environment including maintain temperature within 71-81-degree Fahrenheit when the west wing air-conditioning unit (AC Unit #A) became nonfunctional on 8/26/2026 at 5 AM. This deficient practice not only exposed residents, visitors and staff to excessive room temperatures but also had the potential to cause residents to experience heat-related illnesses, such as heat cramps (painful muscle cramps and spasms), heat exhaustion (more severe than heat cramps and results from a loss of water and salt in the body), and heat stroke (the most severe form of heat illness, occurs when the body's heat-regulating system is overwhelmed by excessive heat. It is a life-threatening emergency and requires immediate medical attention). Findings: During a review of Resident 2 's admission Record, it indicated that the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including but not limited to asthma (a condition in which the airways in the lungs become swollen and narrow, making it difficult to breathe), depressive disorder (an ongoing feeling of sadness and loss of interest in usual activities), and lack of coordination. During a review of Resident 2 's Minimum Data Set (MDS-a resident assessment tool) dated 7/21/2026, the MDS indicated that the resident had moderately impaired cognition (the mental actions or processes of acquiring knowledge and understanding); daily decision-making was moderately impaired. Resident 2 required partial to moderate assistance (the helper performs less than half the effort) with toileting hygiene (the ability to maintain perineal hygiene) and showering/bathing (the ability to bathe oneself). During an observation and interview on 8/26/2026 at 8:45 AM in Resident 2's room, the resident was observed sitting on his bed with the windows open. Resident 2 stated that it was extremely hot and that the room temperature was over 90 degrees (90 ). Resident 2 also said, I couldn't sleep the whole night; I was sweating like crazy. During a concurrent observation and interview on 8/26/2026 at 9:19 AM with Maintenance (MTNC), MTNC used a temperature gun (an infrared thermometer designed to measure surface temperatures from a distance without direct contact) to check the west wing hallway and west wing room temperatures. The recorded temperatures were: [NAME] wing hallway 84.2 degrees Fahrenheit ( F, used to measure temperature)Room A (Resident 2's room): 88.2 [NAME] B: 104.5 [NAME] C: 86.9 [NAME] D: 88.9 [NAME] E: 86.2 [NAME] F: 91.6 [NAME] G: 83.2 F During an interview on 8/27/2026 at 2:13 PM with Registered Nurse (RN 2), RN 2 stated that temperatures greater than 81 F were not acceptable for the comfort of residents and staff. RN 2 stated that this could possibly cause sickness, discomfort, and dehydration to staff and residents. During an interview on 8/27/2026 at 2:29 PM with the Maintenance Director (MD), the MD stated that the air-conditioning board (control board inside the AC unit that controls how the AC operates) for west wing AC unit #A burned out yesterday, 8/26/2026, at around 5AM. It is important to maintain temperature between 71-81 degrees Fahrenheit for comfort. During a concurrent interview and record review on 8/27/2026 at 3:30 PM with the Infection Preventionist Nurse (IPN), the facility's Policy and Procedures (P&P) titled Air Conditioning (AC) Unit Maintenance Policy not dated was reviewed. The IPN stated that the P&P indicated the facility would maintain all air-conditioning and heating, ventilation, and air-conditioning (HVAC) units in safe and properly working condition to provide a comfortable environment for residents, staff, and visitors. The IPN stated that room temperatures must not be lower than 71 F and must not exceed 81 F. The IPN also stated that the P&P was not followed, as the west wing hallway and room temperatures were greater than 81 F, which was not acceptable. This can cause dehydration, a possible asthma attack for Resident 2, and heat-related sickness for staff and residents.

Based on observation, interview, and record review, the facility failed to provide reasonable accommodation of resident needs by failing to ensure that the call light device (one of the major communication technologies that links nursing home staff to the needs of residents) was within reach and answered timely for two (2) of three (3) sampled residents (Residents 1 and 3). This failure had the potential to cause a delay in care for Residents 1 and 3 and prevent the residents from receiving the necessary care and services, which could lead to illness or serious injury.Findings: 1. During a review of Resident 1's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted [DATE] with diagnoses of difficulty of walking, hemiplegia (paralysis or inability to move one side of the body, such as right arm and right leg or the left arm and left leg) and hemiparesis (weakness on one side of the body) and type 2 diabetes mellitus (a disease that occurs when there is a problem in the way the body regulates and uses sugar as fuel) . During a review of Resident 1 's Minimum Data Set (MDS-a resident assessment tool) dated 6/15/2026, the MDS indicated the resident had moderately impaired cognitive skills (the mental actions or processes of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 1 required partial to moderate assistance (helper does less than half the effort) with toilet hygiene (the ability to maintain perineal hygiene), showering and bathing self (the ability to bathe oneself), and toilet transfer (the ability to get on and off the commode). During a concurrent interview and record review on 8/20/2026 at 12:02 PM with the Director of Nursing (DON), of the Resident 1's Fall Risk Evaluation dated 8/11/2026 at 8:43 AM, the fall risk evaluation was reviewed. The DON stated the form indicated the resident was at high risk for fall. During a concurrent observation and interview on 8/21/2026 at 6:32 AM in Resident 1's room with the Administrator (ADMN), Resident 1 was observed lying in bed. The ADMN stated Resident 1's call light was on the floor, and the call bell (an alternate device a resident or patient use to call the staff when they need help) was on Resident 1's wheelchair, which was located at the foot of the bed and out of the resident's reach. The ADMN stated the call light and call bell were out of resident's reach. During a concurrent interview and record review on 8/21/2026 at 12:25 PM with the Treatment Nurse (TN) of Resident 1's Care Plan Report, initiated on 6/17/2026 and revised on 8/11/2026, was reviewed. The TN stated that the care plan indicated that the resident is at risk for falls due to gait and balance problems, a history of falls, incontinence, poor communication, and poor comprehension. The care plan indicated, interventions directed staff to ensure that the resident's call light is within reach and to encourage the resident to use it for assistance as needed and the resident requires prompt responses to all requests for assistance. The TN stated the call light should always be within the resident's reach and easily accessible to prevent accidents such as falls. 2. During a review of Resident 3's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted [DATE] with diagnoses of lack of coordination, paraplegia (partial or complete paralysis [loss of voluntary muscle function] of the lower half of the body with involvement of both legs) and chronic kidney disease (the kidney are damage and do not filter the blood as well as they should for a long period of time). During a review of Resident 3's MDS, dated [DATE], the MDS indicated the resident was cognitively intact with cognitive skills for daily decision making. The MDS indicated Resident 3 was dependent (helper does all of the effort) on eating (ability to use suitable utensils to bring food and liquid to the mouth) and personal hygiene (ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing, and drying face and hands). During a review of Resident 3's Fall Risk Evaluation dated 6/19/2026 at 6:04 PM, the fall risk evaluation indicated the resident was at risk for falls. During a review of Resident 3's Care Plan, date initiated on 6/22/2026 was reviewed, the care plan indicated Resident 3 was at risk for falls due to multiple contributing factors: impaired balance, limited mobility, paraplegia, and chronic kidney disease. During an observation on 8/20/2026 at 1:15 PM, the call light in Resident 3's room was observed to be lit, and the sound was heard in the hallway. Registered Nurse (RN 1) was observed in the hallway (across the room) talking to the pharmacist, and the Licensed Vocational Nurse (LVN 1) was at the nursing station near Resident 3's room sitting. During an interview on 8/20/26 at 1:18 PM with LVN 1 stated he was at the nursing station on 8/20/2026 at 1:15 PM, heard the call light was on from Resident 3's room, but did not answer it. During an interview on 8/20/2026 at 1:19 PM with RN 1, RN 1 stated she heard the call light on 8/20/2026 from Resident 3's room but did not answer it. RN 1 also stated Resident 3 was at risk for falls and that the call light needs to be answered right away to prevent possible accidents, such as falls. During an interview on 8/20/2026 at 1:50 PM with Resident 3, Resident 3 stated that sometimes the nurse takes a long time to answer the call light. During a concurrent interview and record review on 8/20/2026 at 2:05 PM with RN 1, Resident 3's care plan was reviewed. RN 1 stated the care plan, initiated on 6/22/2026, indicated that Resident 3 was at risk for falls due to multiple contributing factors such as impaired balance, limited mobility, paraplegia, and chronic kidney disease. RN 1 also stated the care plan was not implemented because Resident 3's call light was not answered timely. RN 1 further explained that the care plan should be implemented to prevent accidents and falls. During a concurrent interview and record review on 8/20/2026 at 2:08 PM with RN 1, the facility's Policy and Procedures (P&P) titled Answering Call Light, dated 9/2022, was reviewed. RN 1 stated that the P&P indicated the purpose was to ensure timely response to residents' requests and needs. The P&P also stated the call light should be accessible to residents when in bed, on the toilet, in the shower or bathing facility, and from the floor. RN 1 stated that the P&P was not implemented for Resident 1 and 3.

Based on interview and record review, the facility failed to provide treatment and care in accordance with the professional standards of practice for two (2) of 2 sampled residents (Resident 4 and 7) by failing to:Continue and provide wound care treatment per physician (MD) orders for Resident 4.Ensure Resident 7 was seen by a pain specialist (a doctor who has specialized fellowship training in evaluating, diagnosing, and treating acute, chronic, or cancer-related pain) from 1/16/2026 to 4/16/2026 in accordance with the MD order. Thess failures resulted in Resident 4 not receiving wound care treatment for the resident's cervical spine (the uppermost segment of the spinal column) wound for 10 days (2/8/2026 to 2/16/2026 and 2/18/2026) and had the potential to result in Resident 4's cervical spine wound worsening in condition. These failures may result in Resident 7's unmanaged pain and affect the resident's physical well-being and could negatively affect the resident's quality of life. Findings: 1.During a review of Resident 4's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted [DATE] with diagnoses of osteomyelitis (a serious infection within the bone, usually caused by bacteria, that can cause pain, fever and swelling) of vertebra ( the individual, interlocking bones that stack together to form the spine) and intraspinal (within the spinal column) abscess (a localized, swollen, and painful collection of pus [dead tissue, bacteria and white blood cells] that form within tissues or organs) and granuloma (a small nodule or bump). During a review of Resident 4'S Minimum Data Set (MDS – a resident assessment tool), dated 3/5/2026, the MDS indicated the resident was severely impaired (never/rarely made decision) with cognitive (ability to think, remember, and reason) skills for daily decision making. It indicated Resident 4 was dependent (helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) with chair/bed-to-chair transfers and going from sitting to standing. The MDS also indicated Resident 4 needed substantial/maximal assistance (helper does more than half the effort) with going from lying down to sitting on the side of the bed, rolling left and right in bed and putting on/taking off footwear. In addition, it indicated Resident 4 needed partial/moderate assistance (helper does less than half the effort with personal hygiene and lower body dressing (the ability to dress and undress below the waist and needed setup or clean-up assistance (helper set ups or cleans up; resident completes activity) with eating. During a concurrent interview and record review on 4/16/2026 at 12:55 PM with the Director of Nursing (DON), Resident 4's Wound Assessment documentation dated 2/10/2026 and Treatment Administration Record (TAR) dated February 2026 were reviewed. Resident 4's Wound Assessment documentation indicated a treatment order for Resident 4's cervical spine wound of a topical (something applied to a specific body part) application of Dakin's solution (a highly diluted medical-grade bleach solution used as a topical antiseptic to clean and disinfect infected wounds, burns and ulcers) and Betadine (a widely used antiseptic brand containing povidone-iodine that kills germs [bacteria, viruses and fungi] to prevent infection in minor cuts, scrapes and burns) and to cover with a calcium alginate (a highly absorbent, biodegradable [materials that can naturally break down into harmless components] wound dressing made from brown seaweed, designed for moderately to heavily draining wounds) dressing with a daily treatment frequency. Resident 4's TAR indicated no documented administration of treatment for Resident 4's cervical spine wound for 10 days (2/8/2026 to 2/16/2026 and 2/18/2026). The DON stated there is no documentation that Resident 4 received any wound care treatment for the resident's cervical spine wound for 10 days (2/8/2026 to 2/16/2026 and 2/18/2026) and stated treatment should have been done on those days per the wound physician's order on a daily basis which could have resulted in Resident 4's cervical spine wound getting worse. During a concurrent interview and record review on 4/16/2026 at 3:13 PM with Licensed Vocational Nurse 1 (LVN 1), Resident 4's Wound Assessment documentation dated 2/10/2026 and TAR dated February 2026 were reviewed. According to Resident 4's TAR and Wound Assessment documentation, LVN 1 stated there's no documented administration of treatment for Resident 4's cervical spine wound because the last physician (MD) treatment orders stopped on 2/7/2026 and no new orders were input per the wound MD's order as indicated in the Wound Assessment documentation. LVN 1 further stated Resident 4's cervical spine wound treatment orders should have been followed up and input into the system so that there was no delay in care or treatment of the wound. During a concurrent interview and record review on 4/16/2026 at 3:27 PM with the DON, Resident 4's Wound Assessment documentation dated 2/10/2026 and TAR dated February 2026 were reviewed. The DON stated according to Resident 4's TAR and Wound Assessment documentation, there were no new orders input for Resident 4's cervical spine wound treatment from 2/8/2025 to 2/17/2025 and the resident did not receive wound care treatment for 10 days (2/8/2026 to 2/16/2026 and 2/18/2026) which could have potentially made the condition of his cervical spine wound worse. During a review of the facility's policy and procedure (P&P) titled, Pressure Ulcers/Skin Breakdown – Clinical Protocol, revised April 2018, the P&P indicated the physician will order pertinent wound treatments, and application of topical agents. During a review of the facility's P&P titled, Wound Care Treatment Policy & Procedure, revised 2/2/2026, the P&P indicated, It is the policy of this facility to ensure all wound care treatments are performed using aseptic technique, proper hand hygiene, and in accordance with physician orders, to promote healing and prevent infection. The P&P also indicated: Preparation Verify physician's order for wound care treatment Application of Treatment Apply medications/treatments as ordered Responsibilities Licensed Nurse: Perform and document wound care, report changes Treatment Nurse/DON: Monitor compliance and outcomes Infection Preventionist: Audit adherence to infection control practices During a review of the facility's P&P titled, Treatment Administration Policy, revised 2/2/2026, the P&P indicated, The facility ensures that all treatments are administered safely, accurately, and in accordance with physician orders, professional standards of practice, and regulatory requirements. Treatments are performed by qualified personnel and documented timely and completely to reflect the care provided. The P&P also indicated treatments shall be administered as ordered. 2. During a review of Resident 7's admission Record, the admission Record indicated the resident was originally admitted to the facility on [DATE] and was readmitted on [DATE] with the following but not limited to diagnoses of fibromyalgia (a chronic disorder characterized by widespread musculoskeletal pain, fatigue, sleep disturbances, and cognitive issues), muscle weakness, and osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage). During a review of Resident 7's MDS, dated [DATE], the MDS indicated, the resident is moderately impaired in cognitive skills for daily decision making. The MDS also indicated the resident required supervision/touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) with toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, and putting on/taking off footwear. The MDS indicated Resident 7 occasionally have pain which has occasionally limited the resident's day to day activities. The MDS also indicated the resident's had moderate pain within the last 5 days of the assessment. During a review of Resident 7's Physician Orders, dated 1/16/2026, the Physician Orders indicated the following but not limited to: May refer to Pain Specialist Aspirin (Nonsteroidal anti-inflammatory drug [NSAID] used to reduce pain) Oral Tablet 325 milligrams (mg – unit of measure) Give 2 tablet by mouth every 6 hours as needed for breakthrough pain Oxycodone (opioid analgesic to treat moderate to severe pain) 5 mg 1 tab by mouth every 6 hours as needed for moderate to severe pain (4-10/10) every 6 hours as needed. Ibuprofen (NSAID, to treat mild pain) Oral Tablet 400 mg Give 1 tablet by mouth every 6 hours as needed for mild pain (1-3/10) scale During an interview on 4/15/2026 at 1:55 PM in Resident 7's room, Resident 7 stated he has told Social Services Director (SSD) and Licensed Vocational Nurse (LVN) 1 regarding his pain. Resident 7 also stated the facility will give him Aspirin for breakthrough pain, but he will still be in pain. Resident 7 stated LVN 1 would tell him that he would have to wait until his next scheduled pain medication which is the Oxycodone. During an interview on 4/15/2026 at 2:16 PM, Certified Nursing Assistant 2 (CNA 2) stated Resident 7 would be in pain (unable to recall exact dates and times), but when CNA 2 report to the licensed nurses, the licensed nurses would say it is not time for the resident's pain medication yet. During an interview on 4/16/2026 at 1:48 PM, SSD stated she did not follow up with Resident 7's physician's order for a pain specialist and the appointment was not arranged but SSD should have followed up with Resident 7's physician order for a pain specialist. SSD also stated it is important to follow the physician's order for Resident 7 to see a pain specialist to ensure the resident's pain is managed and the resident is comfortable while in the facility. During an interview on 4/16/2026 at 2:20 PM, LVN 1 stated he did not follow up with Resident 7's physician's order for the resident to see a pain specialist but it should have been followed up and implemented. LVN 1 also stated May see a pain specialist means if the resident is having unmanaged pain by the current pain medications, then the resident can see a pain specialist. LVN 1 stated according to the physician's order, Resident 7 can see a pain specialist and the facility needs to ensure the resident's pain is managed. During an interview on 4/16/2025 at 2:30 PM, the Director of Nursing (DON) stated Resident 7's physician's order of May see a pain specialist means if the resident is having unmanaged pain, then the resident needs to see the pain specialist. The DON also stated Resident 7 should have been seen by a pain specialist and it should have been followed up but it was not followed up and it was not done. During a review of the facility's Policy and Procedure (P&P) titled, Pain Management, dated 5/3/2023, the P&P indicated acceptable (tolerable) pain control is defined by the resident and to accurately assess and achieve pain control. During a review of the facility's P&P titled, Appointments, revised 2/2/2026, the P&P indicated the facility will help residents contact specialty providers as needed, based on health recommendations. The P&P also indicated nursing staff informs unit clerk or designee about the appointment order and appointments based on medical necessity.

Based on observation, interview and record review, the facility failed to follow their infection control policy and procedure for two (2) of three (3) sampled residents (Residents 1 and 3) by:1. Not ensuring Registered Nurse 1 (RN 1) changed gloves and performed hand hygiene (washing hands with either an alcohol based hand sanitizer or washing hands) when going from dirty to clean task during wound care treatment for Resident 3 and did not perform hand hygiene after doffing (taking off) personal protective equipment (PPE; clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) after leaving the Resident 3's room.2. Failing to disinfect blood pressure cuff (a medical device, consisting of an inflatable rubber bladder within a sleeve, used to measure blood pressure) before using it on Resident 1.These failures had the potential to result in infection to Resident 3's wound and the spread of infection to other residents in the facility. During a review of Resident 3's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted [DATE] with diagnoses of pressure ulcer (localized damage to the skin and/or underlying tissue usually over a bony prominence) of sacral region (a large, triangular-shaped bone located at the very base of the spine, situated between the lumbar spine [lower back] and coccyx [tailbone]) stage 4 (most severe type of pressure ulcer characterized by full-thickness skin loss that exposes underlying muscle, tendon or bone) and local infection of the skin and subcutaneous tissue (the deepest layer of the skin located directly beneath the dermis [the thick, inner layer of skin located between the outer epidermis and deeper subcutaneous tissue]). During a review of Resident 3'S Minimum Data Set (MDS – a resident assessment tool), dated 1/17/2026, the MDS indicated the resident was moderately impaired with cognitive (ability to think, remember, and reason) skills for daily decision making. It indicated, Resident 3 was dependent (helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) with chair/bed-to-chair transfers, going from lying to sitting on side of the bed, going from sitting to lying down, putting on/taking off footwear, lower body dressing (the ability to dress and undress below the waist) and showering and bathing himself The MDS also indicated Resident 3 needed also needed substantial/maximal assistance (helper does more than half the effort) with personal hygiene and needed partial/moderate assistance (helper does less than half the effort) with rolling left and right in bed, upper body dressing (the ability to dress and undress above [NAME] waist) and needed setup or clean-up assistance (helper sets up or cleans up, resident completes activity) with eating. It further indicated Resident 3 had one stage 3 pressure ulcer that was present upon admission. During a review of Resident 3's Order Summary Report dated 4/16/2026, Resident 3's Order Summary Report indicated an order initiated on 4/13/2026 to apply santyl collagenase ointment (prescription medication used to clean wounds by removing dead, damaged skin [necrotic tissue]) to sacrum stage 4 topically (to a specific surface or spot on the body) and then apply collagen powder (medical-grade, protein-based dressing derived from natural sources that is applied to open, chronic [long-term] or hard-to-heal wounds to jump-start the healing process) and calcium alginate (a highly absorbent, biodegradable [materials that can naturally break down into harmless components] wound dressing made from brown seaweed, designed for moderately to heavily draining wounds) and to cover with a dry dressing every day shift and to also change the dressing when soiled. During an observation on 4/15/2026 at 9:25 AM inside Resident 3's room, RN 1 was observed rendering a wound care treatment for Resident 3's sacrum stage 4 wound. RN 1 was observed to remove Resident 3's dirty dressing and cleaned the wound and did not perform hand hygiene or change her (RN 1) gloves before applying the treatment of santyl collagenase ointment, collagen powder, calcium alginate and covering Resident 3's wound with a dry dressing. During an observation on 4/15/2026 at 9:42 AM inside Resident 3's room, RN 1 was observed doffing (removing) her PPE and throwing it in the trash can and then proceeded to exit the room. RN 1 did not perform hand hygiene, then proceeded to take the treatment cart (a mobile, organized and locked storage unit used by healthcare professionals to transport medical supplies, tools and medications directly to a patient's room) and started walking towards the nurse's station. During an interview on 4/15/2026 at 9:59 AM with RN 1, RN 1 stated she did not change her gloves or perform hand hygiene after cleaning Resident 3's wound because she thought it would be okay since she applied the santyl collagenase ointment and collagen powder onto the wound with a tongue depressor (a disposable spatula/applicator to apply ointments, creams, or gels directly to the wound or skin surface). RN 1 stated however, after applying the ointment and powder to the wound with the tongue depressor, she then touched the calcium alginate and dry dressing and applied it over Resident 3's wound. RN 1 stated she should have changed her gloves and performed hand hygiene before going from a dirty to clean task while performing Resident 3's wound care to have avoided introducing infection to Resident 3's wound since it was already clean and the gloves she had on were contaminated. During the same interview on 4/15/2026 at 9:59 AM with RN 1, RN 1 stated after doffing her PPE and upon leaving Resident 3's room, she should have performed hand hygiene to avoid cross contamination and also because she was leaving the room after doing a treatment and had touched her (RN 1) dirty PPE.During an interview on 4/16/2026 at 12:55 PM with the Director of Nursing/Infection Preventionist (DON/IP), the DON/IP stated when doing wound care, a change of gloves and hand hygiene needs to be performed after removing the resident's dirty dressing and cleaning the wound to avoid contamination of the clean materials for the treatment. The DON/IP stated if hand hygiene was not performed and gloves were not changed; it poses a risk for infection. The DON/IP further stated staff need to perform hand hygiene upon doffing PPE and upon leaving the resident's room to sanitize and not contaminate other objects with what was touched inside the resident's room and to prevent the spread of infection. During a review of the facility's policy and procedure (P&P) titled, Treatment Administration Policy, revised 2/2/2026, the P&P indicated under treatment administration that treatments shall be administered using proper technique and infection control practices and that hand hygiene and standard precautions must be followed at all times. The P&P also indicated under infection control that all treatments must follow infection prevention protocols, including proper wound care technique and cleaning/disinfection of reusable equipment. During a review of the facility's P&P titled, Handwashing/Hand Hygiene, revised February 2026, the P&P indicated, This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. The P&P also indicated: a. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents and visitors.b. Hand hygiene is indicated: Before performing an aseptic task (for example, placing an indwelling device or handling an invasive medical device). After contact with blood, body fluids, or contaminated surfaces. After touching a resident. After touching the resident's environment. Before moving from work on a soiled body site to a clean body site on the same resident. Immediately after glove removal. During a review of the facility's P&P titled, Wound Care Treatment Policy & Procedure, revised 2/2/2026, the P&P indicated, It is the policy of the facility to ensure all wound care treatments are performed using aseptic technique, proper hand hygiene, and in accordance with physician orders, to promote healing and prevent infection. The P&P also indicated its purpose, To provide a consistent, safe, and infection-controlled approach to wound care treatment. The P&P further indicated perform hand hygiene: After exposure to wound/drainage After removing gloves The P&P also indicated the steps for removal of old dressing are as follow: Don clean gloves Remove old dressing carefully Observe wound drainage, odor, color Discard dressing in appropriate waste Remove gloves and perform hand hygiene In addition, the P&P indicated during application of treatment: apply medications/treatments as ordered, use aseptic technique, avoid contamination of supplies, strict adherence to hand hygiene and to not cross-contaminate supplies between residents. 2. During a review of Resident 1's admission Record, the admission Record indicated the resident was originally admitted to the facility on [DATE] and was readmitted on [DATE] with the following but not limited to diagnoses of atrial fibrillation (a common, often irregular, and rapid heart rate causing the heart's upper chambers [atria] to quiver chaotically instead of beating effectively. It increases blood clot, stroke, and heart failure risks), Hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one side of the body caused by brain or spinal cord damage, most commonly from stroke, tumor, or trauma) following cerebral infraction (stroke caused by blood clot blockage in brain blood vessels reducing blood flow to the brain). During a review of Resident 1's MDS, dated [DATE], the MDS indicated the resident was moderately impaired in cognitive skills for daily decision making. The MDS also indicated Resident 1 required partial to moderate assistance c with shower/bathe self and putting on/taking off footwear but required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) with oral hygiene, toileting hygiene, upper body dressing, lower body dressing and personal hygiene. During a review of Resident 5's admission Record, the admission Record indicated the resident was originally admitted on [DATE] and was readmitted on [DATE] with the following but not limited to protein-calorie malnutrition, disorder of kidney (organ that helps filter waste from body) and ureter (urine passes from the kidney to the bladder), and dementia (a progressive state of decline in mental abilities) with anxiety (a feeling of fear, dread, and uneasiness, often characterized by future-oriented worry, apprehension, and physical symptoms like rapid heart rate, tension, and dizziness). During a review of Resident 5's MDS, dated [DATE], the MDS indicated the resident was severely impaired in cognitive skills for daily decision making. The MDS also indicated that the resident was dependent with shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear, putting on/taking off footwear and personal hygiene. During an observation on 4/16/2026 at 8:32 AM, RN 2 was observed checking Resident 5's blood pressure and giving medications to Resident 5. During an observation on 4/16/2026 at 8:38 AM, RN 2 was observed checking Resident 1's blood pressure without disinfecting the blood pressure cuff after using it on Resident 5. During an interview on 4/16/2026 at 9 AM, RN 2 stated she did not disinfect the blood pressure cuff after using it on Resident 5 and prior to using it on Resident 1. RN 2 also stated it is for infection control reasons that is why the BP cuff should be disinfected in between resident use. During an interview on 4/16/2026 at 1:30 PM, Director of Nursing/ Infection Preventionist Nurse (DON/IP) stated, equipment should be disinfected before and after each resident to prevent the spread of infection. During a review of the facility's Policy and Procedure (P&P) titled, Cleaning and Disinfection of Resident-Care Items and Equipment, revised 9/2022, the P&P indicated reusable items are cleans and disinfected or sterilized between residents.

Based on observation, interview and record review, the facility failed to provide pharmaceutical services to meet the needs of two (2) of two sampled residents (Resident 1 and 2) by failing to ensure:a. Resident 1's wrist band (a secure identification bracelet worn by residents to link them to their medical records and alert staff to specific care needs, risks, or safety protocols) was checked prior to medication administration. b. Resident 1's medication Eliquis (blood thinner) was refilled and available. c. Registered Nurse (RN) 2 explained the seven (7) medications that were administered to Resident 1. 2. Director of Staff Development (DSD) accurately reconciled Resident 2's psychotropic (a mind-altering substance that affects mood, thoughts, feelings, perception, or behavior) medication upon admission to the facility.These deficient practices had the potential to result in medication errors (any preventable event that may cause or lead to inappropriate medication use or patient harm) and/or ineffectively managing residents' medical condition, which could result to harm, hospitalization and/ or death.Findings: 1. During a review of Resident 1's admission Record, the admission Record indicated the resident was originally admitted to the facility on [DATE] and was readmitted on [DATE] with the following but not limited to diagnoses of atrial fibrillation (a common, often irregular, and rapid heart rate causing the heart's upper chambers [atria] to quiver chaotically instead of beating effectively. It increases blood clot, stroke, and heart failure risks), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one side of the body caused by brain or spinal cord damage, most commonly from stroke, tumor, or trauma) following cerebral infraction (stroke caused by blood clot blockage in brain blood vessels reducing blood flow to the brain). During a review of Resident 1's Minimum Data Set (MDS – a resident assessment tool), dated 3/18/2026, the MDS indicated the resident was moderately impaired in cognitive (the ability to understand and make decisions) skills for daily decision making. The MDS also indicated Resident 1 required partial to moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with shower/bathe self and putting on/taking off footwear but required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) with oral hygiene, toileting hygiene, upper body dressing, lower body dressing and personal hygiene. During a review of Resident 1's Physician Orders, dated 1/6/2026, the order indicated the following but not limited to: Amlodipine Besylate (blood pressure medication) tablet 5 milligrams (mg – unit of measure) to give 1 tablet by mouth one time a day for hypertension (elevated blood pressure) and hold if systolic blood pressure (measures the maximum pressure in your arteries when the heart beats) is less than 110 (millimeter per mercury- unit of measurement) mmHg. Eliquis oral tablet 2.5 mg to give 1 tablet by mouth two times a day for deep vein thrombosis (DVT - a serious condition where a blood clot forms in a deep vein, usually the leg, causing swelling, pain, warmth, and redness) prophylaxis. Lactulose encephalopathy oral solution (laxative to treat constipation [digestive issue characterized by infrequent bowel movements (usually fewer than three per week), difficulty passing stool, or hard, dry, and lumpy stools]) 10 grams (gm – unit of measure)/15 milliliters (ml – unit of measure) to give 30 ml by mouth one time a day for bowel management hold for loose stool Oyster shell calcium + D (supplement) oral tablet 500 mg/5 micrograms (mcg – unit of measure). Prednisone (treat inflammation, allergic reactions and autoimmune diseases) oral tablet 5 mg to give 1 tablet by mouth one time a day for chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) exacerbation. Metoprolol tartrate (treat blood pressure, chest pain and heart failure) tablet to give 12.5 mg by mouth two times a day. During a review of Resident 1's Physician Orders, dated 1/09/2026, the order indicated to give Famotidine (reduces stomach acid) oral tablet 40 mg, 1 tablet by mouth two times a day for gastroesophageal reflux disease (GERD- a chronic condition where stomach acid frequently flows back into the esophagus, causing persistent heartburn, chest pain, and swallowing issues). During a review of Resident 1's Physician Orders, dated 1/21/2026, the order indicated to give ferrous sulfate oral solution (Iron supplement) 220 mg/5 milliliters, give 5 ml by mouth one time a day for anemia During an interview on 4/15/2026 at 8:07AM, Resident 1's medication administration records (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 04/2026, was reviewed. The MAR indicated the following medications were refused by the resident: Amlodipine Ferrous Sulfate Lactulose Encephalopathy Oyster Shell Calcium + D Prednisone Eliquis Famotidine Metoprolol tartrate During an interview on 4/15/2026 at 8:07 AM, Resident 1 stated he refused his medications today (4/15/2026) because RN 2 did not explain the 7 medications that RN 2 is giving to Resident 1. During a medication administration observation on 4/16/2026 at 8:38 AM, Registered Nurse 2 (RN 2) was observed preparing Resident 1's medications. RN 2 stated they are out of Resident 1's Eliquis and would need to send a request to the pharmacy to refill it. During a medication administration observation on 4/16/2026 at 8:45 AM, RN 2 was observed giving 7 medications to Resident 1 without checking the resident's wrist band or the resident's photograph attached in the resident's medical record to confirm the resident's identity. RN 2 did not explain the types of medication and indication of the 7 medications that the resident is receiving. During an interview on 4/16/2026 at 9 AM, RN 2 stated she did not explain the medications to Resident 1, but she should have explained what medication's indication to the resident before giving the medication to the resident. RN 2 also stated she did not check Resident 1's wrist band to confirm the resident's identity if it is the correct resident before giving the medication. During an interview on 4/16/2026 at 11:10AM, RN 2 stated she did not administer Eliquis to Resident 1 because the medication was not available and the facility did not refill Resident 1's Eliquis medication on time. RN 2 also stated, for Eliquis medication, refills should be done when there are 3 to 2 pills left in the bubble packet (a secure, organized packaging system where pills are sealed)to ensure the facility gets it on time before the resident ran out of the medication stock. During an interview on 4/16/2026 at 1:30 PM, the Director of Nursing (DON) stated during medication administration the licensed nurses should explain what medications including the indication that the licensed nurses are administering to the resident. The DON also stated it is the resident's right to know what medications and the indication of the medication the resident is getting. The DON stated resident identifiers such as the wrist band need to be checked to verify is the correct resident and the medication refills should be done in a timely manner to ensure the resident takes their medication as physician ordered. During a review of the facility's Policy and Procedure (P&P) titled Administering Medications, revised 4/2019, the P&P indicated medications are administered in accordance with prescriber's orders, including any required time frame. The P&P also indicated the individual administering medications verifies the resident's identity before giving the resident his/her medications and methods of identifying the resident include checking identification band (wrist band), checking photograph attached to medical record, and if necessary to verify resident identification with other facility personnel. During a review of the facility's P&P titled Resident Rights Policy and Procedure, revised 10/2025, the P&P indicated residents have the right to be fully informed of their medical condition, treatment options, and changes in care. 2. During a review of Resident 2's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses of unspecified psychosis (a mental health symptom – not a disease itself – characterized by a loss of contact with reality) not due to a substance or known physiological (refers to the normal, healthy functions and processes of a living body or its parts) condition and schizoaffective disorder (a chronic mental health condition combining symptoms of schizophrenia [a chronic severe brain disorder that cause people to interpret reality abnormally] with a major mood disorder [a serious mental health condition characterized by intense, long-lasting emotional disturbances such as deep depression or extreme mania – that interfere with daily functioning)] . During a review of Resident 2's MDS, dated [DATE], the MDS indicated the resident was severely impaired (never/rarely made decision) with cognitive skills for daily decision making. The MDS indicated Resident 2 needed setup or clean-up assistance (helper sets up or cleans up, resident completes activity) with putting on/taking off footwear, personal hygiene and eating. It also indicated, Resident 2 was also independent with walking 50 feet with two turns, chair/bed-to-chair transfers, going from sitting to standing and upper and lower body dressing (the ability to dress and undress above and below the waist). During a review of Resident 2's General Acute Care Hospital (GACH) Discharge Medication Reconciliation documentation dated 3/26/2026, Resident 2's GACH Discharge Medication Reconciliation documentation indicated under All Active Home Medications at time of Discharge Reconciliation on 3/24/2026, an order for risperidone (a prescription antipsychotic medication used to treat schizophrenia, bipolar disorder [a chronic mental health condition characterized by intense, extreme mood swings that interfere with daily life], and irritability associated with autism [a lifelong developmental difference that affects how a person perceives the world, communicates and interacts with others]) 3 mg (milligrams – a unit of measurement) oral tablet give 1 tablet orally 2 times a day. During a review of Resident 2's Order Summary Report dated 3/26/2026, Resident 2's Order Summary Report indicated an order that was input on 3/26/2026 (input by DSD) for risperidone oral table 3 mg, give 3 tablets by mouth two times a day for schizophrenia.During a review of Resident 2's Physician Order Note dated 3/26/2026, Resident 2's Physician Order Note indicated the risperidone order that was input on 3/26/2026 for Resident 2 by DSD was outside of the recommended dose or frequency further indicating the dosing regimen of 3 tablets 2 times per day exceeds the usual dose regimen of 0.02 tablet daily to 0.67 tablet 6 times per day.During an interview on 4/15/2026 at 2:57 PM with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated when a resident is admitted to the facility, the resident's admission packet needs to be reviewed which includes information on what medications the resident needs to continue. LVN 1 stated the resident's primary physician (MD) is then notified of the resident's arrival to the facility and to ask MD if the resident's current or active medications are okay to be continued or not and once approval is received from the MD, the licensed nurse in charge of the resident's admission will start inputting the medication orders for the resident. LVN 1 also stated if ever he would see an alert on the system about a resident's medication order that was input into the system, he would double check the order and alert the Registered Nurse Supervisor to ask if they would be able to double check because often times it was transcribed incorrectly. LVN 1 further stated it is important to double check, reconcile and transcribe a resident's medication orders accurately because of human error and to double check if something was missed by the licensed nurse in charge of the resident's admission. During an interview on 4/16/2026 at 12:35 PM with DSD, DSD stated the process for admitting a resident to the facility, the licensed nurse would get report from GACH and inform the MD that the resident was admitted to the facility, will do medication reconciliation, and the MD will give orders to continue medication orders from GACH unless the MD wants to change something on the resident's medication list. DSD stated when DSD admitted Resident 2 on 3/29/2026, she (DSD) was tired and had transcribed Resident 2's risperidone order in error and instead of putting in the order for 1 tablet twice a day, she put it in for 3 tablets twice a day. DSD stated she did not notice the system had alerted that the dose was above the recommended dose and stated if she had seen the alert, she would have gone back to look through Resident 2's GACH Discharge Medication Reconciliation to double check to see if she reconciled or input the order correctly. DSD further stated there should have been a double checked by another staff member after DSD had input the orders. During a concurrent interview and record review on 4/16/2026 at 12:55 PM with the Director of Nursing/Infection Preventionist (DON/IP), the facility's policy and procedure (P&P) titled, Reconciliation of Medications on Admission, revised July 2017 and Charting and Documentation, revised July 2017 were reviewed. The Reconciliation of Medication on Admission, P&P indicated, The purpose of this procedure is to ensure medication safety by accurately accounting for the resident's medications, routes and dosages upon admission or readmission to the facility and to review the list carefully to determine if there are discrepancies/conflicts. The P&P also indicated, medication reconciliation reduces medication errors and enhances resident safety by ensuring that the medications the resident needs and has been taking continue to be administered without interruption, in the correct dosages and routes, during the admission/transfer process. The Charting and Documentation, P&P indicated, Documentation in the medical record will be objective (not opinionated or speculative), complete and accurate. The DON/IP stated she agreed with the policy and that the medication reconciliation for Resident 2's risperidone on 3/29/2026 was not accurate. The DON/IP also stated after admission orders are input into the system, it is the DON's job to double check and review the next day that the resident's medications were input correctly. The DON/IP further stated it is important that a resident's medications are reconciled accurately to ensure the medications are continued for the resident in the correct dose, route, time and indication.During the same interview on 4/16/2026 at 12:55 PM with the DON/IP, the DON/IP stated because Resident 2's risperidone order was input incorrectly as 3 tablets instead of 1 tablet, the pharmacy would not dispense the medication which is why it was not delivered to the facility and was not given to the resident from 3/27/2026 to 3/29/2026 (3 days). The DON/IP further stated because Resident 2 was not able to take her (Resident 2) risperidone, not taking it could have further aggravated the resident's condition.

Based on observation, interview and record review, the facility failed to develop an individualized resident-centered are plan (a care plan that prioritizes the unique health needs and desired outcomes of the resident) with measurable objectives, timeframe, and interventions for one of two sample residents (Resident 8) to address the Resident 8's behavior of getting out of bed unassisted.This deficient practice has the potential to delay in the necessary care and services for Resident 8, which can potentially result in further falls, injury and harm.Findings:During a review of Resident 8's admission Record, the admission Record indicated the resident was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included difficultly in walking, Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), muscle weakness and dementia (a progressive state of decline in mental abilities).During a review of Resident 8's Fall Risk Evaluation, dated 12/27/2023, the evaluation indicated Resident 8 is at high risk for falls.During a review of Resident 8's Progress Notes, dated 12/10/2025 at 11:00 AM, the progress notes indicated the resident had an unwitnessed fall on 12/9/2025. The progress notes also indicated Resident 8 did not ask for assistance prior to mobility.During a review of Resident 8's Minimum Data Set (MDS - a resident assessment tool), dated 1/27/2026, the MDS indicated the resident is severely impaired in cognitive (the ability to understand and make decisions) skills for daily decision making. The MDS also indicated the resident required substantial/maximal assistance (helper does more than half the effort. Helper lifts or hold trunk or limbs and provides more than half the effort) with toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene but required partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with eating and oral hygiene.During an interview on 4/15/2026 at 2:55 PM, Certified Nursing Assistant 2 (CNA 2) stated Resident 8 has a tendency to get up on her own and has been like that since the resident got admitted to the facility on [DATE].During an interview on 4/15/2026 at 3:28 PM, Licensed Vocational Nurse 1 (LVN 1) stated Resident 8 had a tendency to get up on her own without assistance since the resident was admitted at the facility on 2/14/2026.During an interview on 4/16/2026 at 9:54 AM, Registered Nurse 3 (RN 3) stated Resident 8 would fall because the resident would try to get up on her own without assistance or calling for help. RN 3 also stated most of the time Resident 8 would get up without assistance because the resident needs a adult brief/ diaper change.During an interview on 4/16/2026 at 1:30 PM, Resident 8's Care Plans, dated 9/2/2023 to 2/25/2026, were reviewed. The Director of Nursing (DON) stated there is no care plan addressing Resident 8 getting up on her own and there should be a care plan to address Resident 8 getting up on her own. The DON also stated there is no revision of care plan after Resident 8's fall on 9/27 and there should be a revision every time there is a change in condition.During a review of the facility's P&P titled, Comprehensive Person-Centered Care Plans, dated 3/2022, the P&P indicated the interdisciplinary teams (IDT -a group of professionals from diverse fields working collaboratively, rather than in isolation, to achieve shared goals or comprehensive care for residents) in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. The P&P also indicated the care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The P&P indicated the comprehensive, person-centered care plan describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on observation, interview and record review, the facility failed to accommodate the needs of one (1) of one sampled resident's by failing to ensure the call light (patient-safety device, often a button on a cord, used in hospitals and nursing homes to enable patients to alert staff for assistance, thereby preventing falls and ensuring care) was within reach (arm's length or less than) of Resident 6 on 4/15/2026. This deficient practice has the potential to delay in the necessary care and services and/or needs not being met for Resident 6.Findings:During a review of Resident 6's admission Record, the admission Record indicated the resident was originally admitted on [DATE] and was readmitted on [DATE] with diagnoses that included muscle weakness, chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) and depression (a serious, common mood disorder causing persistent sadness, loss of interest, and physical symptoms that impair daily life for over two weeks). During a review of Resident 6's Minimum Data Set (MDS - a resident assessment tool), dated 3/6/2026, the MDS indicated the resident was moderately impaired in cognitive skills for daily decision making. The MDS also indicated the resident required substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with eating, oral hygiene, upper body dressing and personal hygiene but was dependent (helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) with toileting hygiene, shower/bathe self, lower body dressing, and putting on/taking off footwear. During a concurrent observation and interview on 4/15/2026 at 2:53 PM in Resident 6's room, Resident 6 was observed lying in bed and the resident's call light was on the top right corner of the resident's bed. Resident 6 stated she is thirsty and needs to drink water. Resident 6 also stated the resident cannot reach for the call light to alert the facility staff that she (Resident 6) needs water. During a concurrent observation and interview on 4/15/2026 at 2:55 PM in Resident 6's room, Certified Nursing Assistant 2 (CNA 2) stated Resident 6's call light was placed on the top right corner of Resident 6's bed. CNA 2 stated the call light was not within the resident's reach but should be within the reach of the resident. CNA 2 also stated it is important to have the call light within the resident's reach so the resident can use it in case the resident needs to call the facility staff for assistance. During an interview on 4/16/2026 at 1:30 PM, the Director of Nursing (DON) stated the call light should always be within the resident's reach, so the resident can use it to call the facility when assistance is needed. During a review of the facility's Policy and Procedure (P&P) titled, Answering the Call Light, revised 9/2022, the P&P indicated to ensure that the call light is accessible to the resident when in bed, form the toilet, from the shower or bathing facility and from the floor.

Based on interview, and record review, the facility failed to ensure one of three sampled residents (Resident 2) were free from physical abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish), when Resident 1 allegedly pushed a laundry cart to Resident 2. This deficient practice had the potential to negatively affect Resident 2's comfort and psychosocial (having to do with the mental, emotional, social, and spiritual effects of a disease) well-being which can lead to hospitalization and/or death. Findings:During a review of Resident 1's admission Record, indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), depression (serious medical illness causing persistent sadness, low mood, and loss of interest in activities) and anxiety (a feeling of fear, dread, and uneasiness, often accompanied by physical symptoms like rapid heart rate, sweating, or tension). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 3/29/2026, the MDS indicated Resident 1's cognitive (ability to think and reason) skills for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated Resident 1 was independent (resident completes the activity) with upper and lower body dressing. The MDS indicated Resident 1 required setup or clean-up assistance (helper sets up or cleans up) with eating, oral hygiene, putting on/taking off footwear and personal hygiene. The MDS indicated Resident 1 required supervision or touching assistance (helper provides verbal cues; resident completes activity) with toileting hygiene and shower/bath. The MDS indicated Resident 1 was independent with lying to sitting on side of bed, sit to stand, walk 10 feet (unit of measurement), and walk 50 feet with two turns. During a review of Resident 1's Change in Condition (COC) Evaluation, dated 3/29/2026, timed 1:25 PM, documented by Licensed Vocational Nurse 1 (LVN 1), indicated a situation of alleged physical altercation (physical contact or force and may include bullying, fighting, or violence) towards another resident (no specific resident indicated).). The COC Evaluation indicated Resident 1 has physical and verbal aggression. The COC Evaluation indicated Resident 1 was yelling profanities towards others and shoving objects at other residents (no specific resident indicated). During a review of Resident 2's admission Record, indicated Resident 2 was admitted to the facility on [DATE], readmitted om 12/24/2025, with diagnoses that included abnormal posture, lack of coordination and heart failure (condition where the heart muscle cannot pump enough blood to meet the body's needs for oxygen and nutrients). During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2's cognitive skills for daily decision making was moderately impaired (decisions poor; cues/supervision required). The MDS indicated Resident 2 required setup or clean-up assistance with eating. The MDS indicated Resident 2 required supervision or touching assistance with oral hygiene. The MDS indicated Resident 2 required partial/moderate assistance (helper does less than half the effort) with upper body dressing and personal hygiene. The MDS indicated Resident 2 was dependent (helper does all the effort) with toileting hygiene, shower, lower body dressing and putting on/taking off footwear. The MDS indicated Resident 2 uses wheelchair. During a review of Resident 2's COC Evaluation, dated 3/29/2026, timed 1:25 PM, documented by Registered Nurse 1 (RN1), indicated a situation of alleged physical aggression (intentional behavior designed to cause bodily harm or damage) received from another resident (no specific resident indicated). During a review of the facility's interview record, dated 3/29/2026, indicated Visitor 1 stated Visitor 1 came to visit a resident in room [ROOM NUMBER]. It also indicated Visitor 1 stated we heard some yelling close to the room, so I peeked out to check and one of the resident (Resident 1) was screaming at another resident (Resident 2) who was in his (Resident 2) wheelchair. Resident 1 pushed a laundry basket hitting the other resident (Resident 2), and he (Resident 2) yelled ouch. The lady (Resident 1) was walking towards the shower after and was cursing at the other man (Resident 2). During an interview on 3/8/2026 at 2:35 PM with Certified Nurse Assistant (CNA) 1, CNA 1 stated Resident 1 has been rude and verbally aggressive to staff. CNA 1 stated Resident 1 had episode of throwing things on the floor inside the room. CNA 1 stated Resident 1 can be really aggressive and unsafe to other residents. During an interview on 4/8/2026 at 4 PM, with admission Director (AD), she stated that on 3/29/2026, she was walking with Resident 1 to the shower room. AD stated Resident 1 got upset about how the facility's shower looks like. AD stated she had to leave Resident 1 at the hallway briefly to get more towels, and the incident between Resident 1 and Resident 2 happened in the same hallway where she is heading to get more towels. Visitor 1 called AD, and as AD turned her back to check the 2 residents, Resident 2 who was sitting in the wheelchair, located in the middle of the hallway, was observed with laundry cart behind the wheelchair and heard Resident 1 shouting at Resident 2 in the hallway. AD stated laundry cart is usually placed at the side of the hallway and never placed in the middle of the hallway. AD stated Visitor 1 told her that Resident 1 pushed the laundry cart to Resident 2. During an interview on 4/8/2026 at 4:18 PM with Licensed Vocational Nurse (LVN) 1, LVN 1 stated on 3/29/2026, around 1:25 PM, LVN 1 heard Resident 2 saying ouch, and Resident 1 saying you fucking pigs, I hate this place, in the hallway. LVN 1 stated Visitor 1 told him (LVN 1) that Resident 1 pushed laundry cart to Resident 2. During a concurrent interview and record review with the Director of Nursing (DON) on 4/9/2026 at 4:50 PM, Resident 1's medical records (including physician's order, Medication Administration Record [MAR], treatment Administration Record [TAR] and progress notes) dated 3/26/2026 to 3/29/2026 were reviewed. Resident 1's medical records did not indicate an order to monitor Resident 1's aggressive behavior of throwing things at other people. The DON stated Resident 1 already manifested aggressive behavior of throwing things to other people on the resident's second day in the facility and the resident's aggressive behavior was not monitored by the facility staff, and it should have been included in the resident's behavior monitoring. The DON also stated the facility failed to prevent Resident 1 pushing the laundry cart to hit Resident 2. During a review of the facility's Policy and Procedure (P&P), titled Abuse and Neglect (the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress) -Clinical Protocol, revised in March 2018, the P&P indicated he facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect.

Based on interview and record review, the facility failed to provide necessary care and treatment for one (1) of two (2) sampled residents (Resident 1) with urostomy (a surgical procedure creating a permanent opening on the abdomen to divert urine out of the body), in accordance with the facility's urostomy and self-catheterization policy by failing to:Obtain physician order for self-catheterization (a safe, routine procedure used four to six times daily to drain urine from the bladder using a flexible tube).Assess and monitor Resident 1's capability to perform self-catheterization.Maintain a daily record of Resident 1's daily fluid intake and output per Facility's Policy and Procedures (P&P).Inspect the condition of the skin around the stoma for any irritation or breakdown.Document Resident 1's time and frequency of catheterization. This deficient practice had the potential to result in complications of urostomy such as peristomal skin irritation (caused by leakage resulting in sore, red or inflamed skin), urinary tract infection, stoma leaks and long-term risk such as metabolic acidosis (too much acid in the blood).Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE], with diagnosis which included retention of urine, paraplegia (loss of movement and/or sensation, to some degree, of the legs), and lack of coordination. During a review of Resident 1's Admit/Readmit Data Collection and Baseline record dated 3/24/2026, the record indicated under skin condition assessment that Resident 1 has an opening on right lower abdomen for bladder movement, uses straight catheter for voiding. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 3/30/2026, the MDS indicated Resident 1's cognitive skills (processes of thinking and reasoning) for daily decision making was independent (decisions consistent/reasonable). The MDS indicated Resident 1 required setup or clean-up assistance (helper sets up or cleans up) with eating. The MDS indicated Resident 1 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with oral hygiene. The MDS indicated Resident 1 required partial/moderate assistance (helper less than half the effort) with putting on/talking off footwear. Resident 1 was dependent on toileting hygiene, shower, upper and lower body dressing. The MDS also indicated Resident 1 has an appliance for ostomy (a surgically created opening, or stoma, on the abdomen that redirects bodily waste [stool or urine]) and was always incontinent for urinary continence. During a review of Resident 1's Order Summary Report, dated 4/7/2026, the Order Summary Report indicated a physician's order, dated 3/30/2026 to cleanse right lower abdomen urostomy site with normal saline, pat dry and leave open to air. During a concurrent observation in Resident 1's room and interview on 4/7/2026 at 10:30 AM, Resident 1 was observed lying in bed. Resident 1 stated that she takes care of her urostomy. Resident 1 refused to show her right lower quadrant stoma and stated does self-catheterization but did not provide details. Resident 1 stated that she would request some of the supplies like gauze from the staff, but she has her personal supplies for the most part. During an interview on 4/7/2026 at 1:18 PM with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated Resident 1 does self-catheterization. LVN 1 stated he never assisted or observed Resident 1 care for her urostomy. LVN 1 stated he was not aware of Resident 1's skin condition around the stoma. During a concurrent record review and interview on 4/7/2026 at 2:54 PM with Registered Nurse (RN 1), Resident 1's medical records were reviewed. RN 1 stated that Resident 1 did not have a urostomy care order since admission date of 3/24/2026 to 3/30/2026. RN 1 stated Resident 1's urostomy care was not done from 3/24/2026 to 3/30/2026. RN 1 stated Resident 1's does self-catheterization but was nt aware how often does Resident 1 performs it. RN 1 stated that there were no physician's orders, assessments and documented evidence that Resident 1 can safely do self-catheterization. RN 1 stated there were no records to indicate how many times Resident 1 does self-catheterization in a day. RN 1 also stated there were no records to indicate that Resident 1's urine output and its characteristics were assessed. RN 1 stated Resident 1's care plan for urostomy was only developed on 4/5/2026. RN 1 stated Resident 1's admission baseline care plan did not indicate how to care for Resident 1's urostomy. RN 1 stated there was no documented evidence that Resident 1's intake and output were monitored. During a concurrent record review and interview on 4/7/2026 at 3:25 PM with Infection Prevention Nurse (IPN), Resident 1 medical records were reviewed. IPN stated Resident 1 was not and should have been evaluated if she is able to perform self-catheterization. IPN stated knowing Resident 1s' capability and understanding of urostomy care upon admission was important to ensure that Resident 1 understands the procedure, and it could have been done by Resident 1's demonstration and verbal explanation of urostomy care. IPN verified that Resident 1 did not have an order for self-catheterization, and no care plan was developed as well. IPN stated it was important to have an order for urostomy care upon Resident 1's admission to the facility for all staff to safely provide the care needed. During a record review of the facility's undated Policy and Procedures (P&P) titled Urostomy/Ureterostomy Care, the P&P indicated that these procedures are to promote cleanliness and to protect peristomal skin from irritation, breakdown, and infection. It also indicated the following general guidelines:Determine if the resident is on intake or output before discarding urine.Check urine for unusual appearance and record findings.Maintain a daily record of residents' daily fluid intake and output, as indicated.Inspect the condition of the skin around the stoma for any irritation or breakdown. If present, notify the supervisor and physician immediately.A resident with established stoma may prefer to change their own ostomy pouch. Check the plan of care and follow the resident's stated preference. During a record review of the facility's undated P&P titled Self-Catheterization, the P&P indicated residents who are assessed and deemed capable may perform self-catheterization in accordance with physician orders. Nursing staff will provide education, supervision (as needed), and ongoing monitoring to ensure safety and compliance with infection control standards. The P&P indicated to verify physician order for self-catheterization and document competency prior to initiation. The P&P also indicated to document the following:Resident competencyFrequency and toleranceAny complicationsResident competencyFrequency and tolerance

Based on interview and record review, the facility failed to ensure appropriate competencies and skills sets to provide nursing and related services were completed for five (5) of 5 sampled employees in accordance with facility's policy and procedures (P&P). This deficient practice has high potential to cause an increased risk for improper resident assessments, inadequate documentation, and could negatively impact the quality of care to the residents which could lead to hospitalization or death.Findings:1. During a review of Certified Nurse Assistant 2 (CNA 2)'s skills check evaluation competency, dated 12/23/2025, indicated a blank box where initial skills check date was performed. The form indicated under instructions that the Director of Staff Development (DSD)/ Facility Approved Nursing Training Instructor/ Responsible Appropriate Designee - will complete Initial CNA skills check evaluation competency for all onboarding CNA employee participant following education training provided upon new hire orientation and onboarding process, annually, and as deemed necessary by the Director of Nursing (DON)/Administrator/Appropriate Designee. The form also indicated, the instructor will check the appropriate column (either U [unsatisfactory] or S [satisfactory]) with dates of observations in the spaces provided following review of each skill and only few check marks were seen in the form, with no documentation of dates when the tasks were evaluated. During a concurrent record review and interview on 1/23/2026 at 9:05 AM with Director of Staff Development (DSD), CNA 2's employee file (personal records) was reviewed. DSD stated the employee file indicated CNA 2 was hired on 12/23/2025. DSD stated she conducted CNA 2's skills check evaluation competency on 12/23/2025. DSD explained that CNA 2 was able to perform all tasks in the checklist, that is why DSD checked off the first box of satisfactory and drew a line down to indicate that all the tasks down the list are satisfactory. DSD stated the last page (page 3) of the skills check evaluation competency, the box for CNA 2's signature and date signed was blank. DSD stated the skills check evaluation competency for CNA 2 is incomplete because there are no dates documented when the tasks were completed/ skills were evaluated, and no documentation on the comments section of which type of evaluation was used to evaluate specific tasks. DSD stated she completed the skills evaluation for CNA 2 by actual observation of the skills to residents on 12/23/2025. DSD refused to answer how she evaluated CNA 2 for the choking and Heimlich maneuver (first-aid procedure for dislodging an obstructions from a person's airway/ windpipe in which a sudden strong pressure is applied on the abdomen, between the navel and the rib cage) tasks. 2. During a review of CNA 3's skills check evaluation competency, dated 1/7/2026, indicated a blank box where initial skills check date was performed. The form indicated under instructions that the DSD/ Facility Approved Nursing Training Instructor/ Responsible Appropriate Designee - will complete initial CNA skills check evaluation competency for all onboarding CNA employee participant following education training provided upon new hire orientation and onboarding process, annually, and as deemed necessary by the DON/Administrator/Appropriate Designee. The form also indicated, the instructor will check the appropriate column (either U or S) with dates of observations in the spaces provided following review of each skill and only few check marks were seen in the form, with no documentation of dates when the tasks were evaluated. During a concurrent record review and interview on 1/23/2026 at 9:15 AM with DSD, CNA 3's employee file (personal records) was reviewed. DSD stated the employee file indicated CNA 3 was hired on 1/6/2026. DSD stated she conducted CNA 3's skills check evaluation competency on 1/7/2026. DSD stated CNA 3 was able to perform all tasks properly, that is why she thinks CNA 3 is competent to do her (CNA 3) job. DSD stated she was trying to do short-cut with filling in the forms, so she only wrote S in the first box of the satisfactory column and drew line all the way down the check list. DSD stated the skills check evaluation competency for CNA 3 is incomplete because there are no dates documented when the tasks were completed, and no documentation on the comments section of which type of evaluation was used to evaluate specific tasks. DSD stated it is important to evaluate CNA's skills competency before releasing them from orientation to know if the employee needs more training and to ensure resident's safety. DSD stated the evaluation must not have been done correctly for CNA 2 and 3 because each task was not checked off, and no documentation of how the skill was validated. DSD stated not all the tasks on list were observed, some were discussed verbally. DSD stated she should have not drew a line down the list and should have added a check mark on each skill once evaluated with the date of evaluation to ensure all the tasks were completed. 3. During a review of Licensed Vocational Nurse (LVN 2)'s Performance Evaluation (a formal, periodic review where a manager assesses how well a nurse is performing their job, often comparing their work to set standards and goals) dated 9/11/2024, indicated LVN 2 meets expectations (performance is at average, acceptable level, some interest in improving and positive behavior about their job and the facility) for completing tasks on time, and meeting job requirements. During a review of LVN 2's undated Skills checklist - Licensed Nurse Medication (Med) Administration, indicated skill proficiencies will be evaluated by describing the procedure and/or return demonstration. The form indicated check marks in the met column, and no description describing how the skills were evaluated. The form did not indicate name of evaluator or observer. During a review of LVN 2's undated and untimed Med Pass (the organized, scheduled process where nurses distribute prescribed medications to residents) form. The form indicated check marks in the correct column, and no description describing how the skills were evaluated. The form indicated a date and time box, and consultant/observer were left blank. During a review of LVN 2's participant certification of skills competency evaluation, dated 5/6/2025, indicated the employee has been provided both pre/post quiz review and skills training competency review with ample opportunity provided to demonstrate having sufficient knowledge and ability needed to apply skills for practice in respective to his/her role in the facility. It also indicated instructor to check applicable and provide a signature to certify that all components of the skills competency review and requirements have been met. Med Administration and Dietary were not checked or marked During an interview on 1/23/2026 at 9:45 AM with DSD, DSD stated LVN 2's skills competency on 5/6/2025 indicated no check mark on the med administration and dietary box. DSD stated it means that the evaluation was not done, or the employee failed the training. DSD stated all employees should have a good result for their skills competency evaluation to make sure that they are competent in providing the necessary care for the residents. 4.During a review of Registered Nurse Supervisor 3's (RNS 3) new hire employee orientation day 1 and day 2 training acknowledgement review checklist, conducted by DSD, reviewed on 11/17/2025, indicated new hire employee will review checklist below to ensure review of all subjects listed as it pertains to employment procedures in facility, and employee will initial column for competency. Last page of the form indicated a blank box under the employee signature and date orientation topics were provided. During a concurrent record review and interview on 1/23/2026 at 9:50 AM with DSD, RNS 2's employee file was reviewed. DSD stated the employee file indicated the facility hired RNS 2 on 11/17/2025, and she (DSD) conducted the basic orientation of the facility to RNS 2 on the same day (11/17/2025). DSD stated RNS 2's skills competency upon hire was evaluated by Director of Nursing. DSD validated RNS 2's licensed nurse skills evaluation/orientation checklist is nowhere to be found in RNS 2 's employee folder. DSD stated all employees should have an upon hire skills evaluation to ensure the employee is competent and capable of caring for the residents. During an interview on 1/23/2026 at 10:55 PM with facility's consultant (FC), FC verified, RNS 2's Licensed Nurse Skills Evaluation/Orientation Checklist was not in RNS 2's employee file folder. FC stated skills competency evaluation should always be kept in the employees' profile to ensure availability at times that it needs to be accessed. FC stated maintaining employee files complete is important to have documented evidence of employees record and proof that evaluation was done before the employee is released to work independently. FC stated the DON is supposed to conduct the upon hire skills competency for registered nurses and not the DSD, then the DON will submit the forms to DSD for employee file records. 5. During a review of RNS 4's undated new hire employee orientation day 1 and day 2 training acknowledgement review checklist, conducted by DSD, indicated new hire employee will review checklist below to ensure review of all subjects listed as it pertains to employment procedures in facility, employee will initial column for competence. The checklist consisted of one page and did not include the other 2 pages and did not indicate date of review. The checklist indicated one check mark and a line drawn down then list and no RN 4's initial to acknowledge the training was provided upon second day orientation. During a review of RNS 4's Licensed Nurse Skills Evaluation/Orientation Checklist, it indicated RNS 4's date of hire was 9/8/2025. The checklist instructions to place S (satisfactory) or U (Unsatisfactory) with dates of observations on the space provided. The checklist is to be completed on orientation, annually and as deemed necessary by the DON/Administrator. During a review of RNS 4's Skills checklist-Licensed Nurse Medication Administration, dated 9/8/2025, indicated skill proficiencies will be evaluated by describing the procedure and/or return demonstration. The skills checklist indicated 22 check marks under the column met out of the 29 skills for evaluation. The form did not indicate description of how the 22 skills were evaluated. The DON's name and signature was indicated on the last page, RN4's signature and date were left blank, and the DSD's signature and date was also left blank. During a review of RNS 4's medication pass evaluation form, dated 11/4/2025, indicated evaluator gave RNS 4 a handout, and the following were not marked as correct and reviewed with RNS 4:Identifies residents by wristband or current photograph.Always provides privacy for all procedures except oral administration.Residents are assessed for pain during med pass.Uses proper injection administration, technique and appropriate site.Uses proper ophthalmic medication administration technique.Uses proper nasal administration techniquesThe form did not indicate that RNS 4 is ready to work at bedside. During an interview on 1/23/2026 at 7:45 PM with Administrator (ADM), the ADM stated she did not know why the employee files were incomplete. ADM stated the employee files should always be accessible for review and if specific training is not in the file, it means it was not done. ADM stated the DON and DSD are the one who is conducting the orientations to nurses, they should be more organized and have a process to ensure that employee files and competency skills check are complete and up to date. During a review of facility assessment, reviewed with Quality Assurance and Performance Improvement (QAPI takes a systematic, interdisciplinary, comprehensive, and data-driven approach to maintaining and improving safety and quality in nursing homes while involving residents and families in practical and creative problem solving) on 11/26/2025, and updated on 1/16/2026, indicated staff training/education and competencies includes CNA/ skills competency checks annually or as needed, RN/LVN license competency testing annually or as needed. During a review of facility's P&P titled Personnel Records, revised in January 2008, indicated the facility maintains certain records for each employee which are directly related to his/her employment. The P&P also indicated personnel records may be retained at the facility under supervision of facility appointed designee per Administrator and the records must contain, as each may apply, the following date:Orientation and training program recordsPerformance evaluation

Based on observation, interview, and record review, the facility failed to ensure proper food handling and maintain the food service area in a clean and sanitary manner in accordance with the facility's policies and procedures (P&P) when: The can opener was chipped and soiled with food residue.The blender was chipped and inside the jar showed white to yellowish discoloration around the blade.The onion powder container lid was partially closed and did not have a label to indicate open and discard date.The stand mixer (used for mixing, whisking, and kneading ingredients) had peeling and chipped paint, with exposed metal on the adjustment handle.The coffee maker's spout (the part where the coffee flows out into the pot or cup) was cracked. These deficient practices have the potential to expose residents to pathogens (germs), placing them at risk for developing foodborne illness (food poisoning), which may cause symptoms such as upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever which could lead to serious medical complications and hospitalization.Findings: During an observation on 1/20/2026 at 7:40 AM in the facility's kitchen, the can opener was observed to be chipped and soiled with food residue. The blender was chipped and inside the jar showed white to yellowish discoloration around the blade. During an observation on 1/20/2026 at 7:41 AM in the facility's kitchen, the onion powder container lid was partially closed and did not have a label to indicate open and discard date. During an observation on 1/20/2026 at 7:42 AM in the facility's kitchen, the stand mixer had peeling and chipped paint, with exposed metal on the adjustment handle. The spout of the coffee maker was observed to be cracked. During an interview on 1/22/2026 at 1:19 PM with the Dietary Supervisor (DS), the DS stated that the coffee maker pot was cracked, the stand mixer paint was chipped and peeling, the onion powder lid was not properly closed and was not dated, and the can opener was chipped and had marinara sauce residue. The DS stated that all lids are supposed to be properly closed and dated with open and discard dates. The DS also stated that the can opener should be washed daily after use and that all equipment should be maintained in good condition to prevent food contamination, which could possibly cause illnesses such as diarrhea and stomach aches. During an interview on 1/23/2026 at 7:32 AM with the Cook, the [NAME] stated that the can opener should be cleaned after every use. The [NAME] stated that all opened food should be labeled, dated, and sealed properly. The [NAME] also stated that all equipment should be in good condition to prevent sickness. During a review of the facility's undated P&P titled, Food Storage, the P&P indicated that all opened and partially used foods shall be dated, labeled, and sealed before being returned to the storage area. During a review of the undated facility's P&P titled, Safety and Sanitation, the P&P indicated that Food and nutrition services employees shall perform job responsibilities in a safe and sanitary manner. The P&P also indicated that any equipment making unusual noises, giving off odd odors, or operating in an abnormal manner will be reported immediately. Equipment should be turned off, unplugged, and a do not use sign attached until it is evaluated, repaired, and found to be safe to use.

Based on observation, interview, and record review, the facility failed to ensure its medication error rate was less than five (5) percent (%). 13 medication errors (the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order/ manufacturer's specifications / accepted professional standards and principles out of 35 total opportunities (observed administered medications) for error, to yield an overall medication error rate of 37.14 % for two (2) of six (6) sampled residents (Resident 10 and Resident 17) observed for medication administration.Licensed Vocational Nurse 2 (LVN 2) failed to administer Resident 17's medications, and Registered Nurse Supervisor 4 (RNS4) failed to administer Resident 10's medication within 60 minutes of the scheduled time of 9 AM on 1/22/2026.This deficient practice had the potential to result in Resident 17 and Resident 10 experiencing adverse medication effects (unwanted, uncomfortable, or dangerous effects that a medication may have), negatively impacting their health and well-being.Findings:1. During a review of the admission Record, the admission Record indicated Resident 17 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 17's diagnoses included were benign prostatic hyperplasia (BPH, health issue with urination, problems like a weak stream, difficulty starting to pee, and frequent urination), dementia (a progressive state of decline in mental abilities), and hypertensive heart disease (long-term high blood pressure) with heart failure (the heart can't pump).During a review of Resident 17's Minimum Data Set (MDS - a resident assessment tool) dated 7/12/2025, the MDS indicated Resident 17 had modified independence (some difficulty in new situations only) with cognitive (thought process and ability to reason or make decisions) skills for daily decision making. The MDS indicated Resident 10 was dependent (helper does all the effort) on staff for toileting hygiene, shower, upper and lower body dressing, and putting on/taking off footwear. The MDS indicated Resident 10 required substantial/maximal assistance (helper does more than half the effort) from staff with eating, shower and personal hygiene.During a review of Resident 17's Order Summary Report, dated 1/21/2026, the Order Summary Report indicated the following orders:Ascorbic acid (vitamin C, essential, water-soluble nutrient found in fruits and vegetables that the human body cannot produce on its own) oral tablet, give 1 tablet by mouth two times a day for supplement, ordered on 12/11/2025. Bethanechol chloride (used to treat urinary retention) oral tablet 10 milligrams (mg, unit of measurement), give 1 tablet by mouth three times a day for urine retention, ordered om 12/11/2025. Carbidopa-Levodopa (medication used to treat Parkinson's disease [a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements] symptoms like tremors, stiffness, and slowness) oral tablet 25-100 mg, give 1 tablet by mouth one time a day for Parkinson's disease, ordered om 12/11/2025. Docusate sodium oral tablet 100 mg, give 1 tablet by mouth two times a day for bowel management, hold for loose stools, ordered on 1/21/2026. Escitalopram oxalate (medication used to treat depression) oral tablet 10 mg, give 1 tablet by mouth one time a day for depression manifested by verbalization of sadness, ordered on 12/11/2025. Lactobacillus oral tablet, give 1 capsule by mouth, once a day for probiotic (bacteria and yeasts, that provide health benefits when consumed), ordered on 1/21/2026. Furosemide (medication used treat fluid retention) oral tablet 40 mg, give 1 tablet by mouth two times a day for congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), hold if systolic blood pressure (SBP, the top/higher number in a reading, representing the pressure when your heart beats and pumps blood out) is less than 110 or heart rate of less than 60, ordered on 12/11/2025.During a medication administration observation on 1/22/2026 at 11:03 AM, with LVN 2, LVN 2 prepared and administered the following six (6) medications to Resident 17: Ascorbic acid oral tablet, 1 tablet. Bethanechol chloride oral tablet 10 mg, 1 tablet. Carbidopa-Levodopa oral tablet 25-100 mg, 1 tablet Docusate sodium oral tablet 100 mg, 1 tablet. Escitalopram oxalate oral tablet 10 mg, 1 tablet. Lactobacillus oral tablet, 1 capsule.During an interview on 1/22/2026 at 11:26 AM, LVN 2 stated that he administered Resident 17's medications, which were scheduled for 9 AM, late-after the one-hour window-because he was busy with another resident.2. During a review of the admission Record, the admission Record indicated Resident 10 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 10's diagnoses included diabetes mellitus (high blood sugar), encounter for attention to gastrostomy (G-tube, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), and lack of coordination.During a review of Resident 10's (MDS - a resident assessment tool) dated 1/2/2026, the MDS indicated Resident 10 had severely impaired cognitive skills for daily decision making. The MDS indicated Resident 10 was dependent on staff for eating, oral hygiene, toileting hygiene, shower, upper and lower body dressing, putting on/taking off footwear and personal hygiene.During a review of Resident 10's Order Summary Report, dated 1/21/2026, the Order Summary Report indicated the following orders:Ativan (medication used as a powerful sedative and calming agent) oral tablet 0.5 mg, give 1 tablet via G-Tube every 12 hours for unspecified anxiety (a natural human feeling of fear, dread, or intense worry) disorder manifested by constantly yelling for no apparent reason, ordered on 10/3/2025.Baclofen (medication used as muscle relaxant) oral solution 5 mg/5ml, given 5 ml via G-tube one time a day for muscle relaxants, ordered on 1/19/2025.Benztropine mesylate (medication used to treat movement disorders and muscle spasms) oral tablet 0.5 mg, give 1 tablet via G-Tube every 12 hours for extrapyramidal (Involuntary or uncontrollable muscle movements and body stiffness) and movement disorder, ordered on 10/3/2025.Escitalopram oxalate oral solution 5 mg/5ml, give 10 ml via G-Tube one time a day for depression manifested by constant crying for no apparent reason, ordered on 10/3/2025.Esomeprazole magnesium (medication that works by reducing the amount of acid produced in the stomach) oral packet 40 mg, give 1 packet via -tube, two times a day for Gastroesophageal Reflux Disease (GERD, a chronic condition where stomach acid frequently flows back up). Mix contents of 1packet with 15 ml of water and leave 2-3 minutes to thicken. Stir and administer within 30 minutes of mixing, ordered on 10/3/2025.Senna (plan-based medicine to treat constipation) oral tablet 8.6 mg, give 1 tablet via G-Tube two times a day for bowel management, hold for loose stool, ordered on 10/3/2025Zyprexa (olanzapine, medication used to treat serious mental health conditions) oral tablet 2.5 mg. Give 1 tablet via G-Tube two times a day for schizophrenia (a mental illness that is characterized by disturbances in thought) manifested by striking out at staff during activities of daily living. Ordered on 10/3/2025.During a medication administration observation on 1/22/2026 at 12:44 PM, RNS 4 prepared and administered the following six (7) medications to Resident 10:Ativan oral tablet 0.5 mg, 1 tablet.Baclofen oral solution 5 mg/5ml, 5 ml.Benztropine mesylate oral tablet 0.5 mg, 1 tablet.Escitalopram oxalate oral solution 5 mg/5ml, 10 ml liquid solution.Esomeprazole magnesium oral packet 40 mg, 1 packet.Senna oral tablet 8.6 mg, 1 tablet.Zyprexa (olanzapine) oral tablet 2.5 mg. 1 tablet.During an interview on 1/23/2026 at 11:27 AM, RNS 3 stated failing to administer medication to a resident as ordered by the physician can lead to medical complications, possibly resulting in hospitalization. RNS 3 stated the facility's morning medication administration time is scheduled for 9 AM, and medications may be administered one hour before or after 9 AM. RNS 3 further stated if medications are administered late or early, the licensed nurse must notify the physician and document the reason for the delay in the resident's progress notesDuring an interview on 1/23/2026 at 12:11 PM, LVN2 stated on 1/22/2026, Resident 17's 9 AM medications were administered outside the one-hour window. LVN 2 stated when administering medications to his assigned residents, he takes time to check their vital signs, such as blood pressure, and pays attention to residents who want to speak with him. LVN 2 stated he should have delegated the administration of medications for other residents who had not received their 9 AM doses to another licensed nurse in the facility, such as the RN Supervisor, Director of Staff Development, Infection Preventionist Nurse, MDS Nurse, or Director of Nursing (DON). LVN 2 stated it is important to administer medications on time and as ordered by the physician to ensure efficacy and avoid possible adverse reactions or side effects that the resident may experience.During an interview on 1/23/2026 at 7 PM, the DON stated not following a physician's order constitutes a medication error. The DON confirmed that LVN 2 administered Resident 17's 9 AM medications late on 1/22/2026 and that RNS 4 also administered Resident 10's 9 AM medications late on the same day. The DON stated medications may be administered one hour before or after the scheduled time but should not exceed that window, as doing so is considered a medication error. The DON added when LVN 2 and RNS 4 were having difficulty administering medications within the allotted time, they should have asked for assistance so another licensed nurse could help. The DON stated, If medications are not administered on time, for example, anti-anxiety medications, it can affect the mood and behavior of residents, which can impact their activities of daily living (ADLs).' The DON also added failing to administer medication as ordered by the physician can lead to medical complications, possibly resulting in hospitalization.During a review of facility's Policy and Procedure (P&P) titled, Administering Medications, revised in April 2019, the P&P indicated medications are administered in a safe and timely manner, and as prescribed. It indicated medications are administered in accordance with prescriber orders, including any required time frame. The P&P indicated medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders) or ordered by the physician. The P&P also indicated medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered included:Enhancing optimal therapeutic effect of the medication.Preventing potential medication or food interactions.

Based on observation, interview, and record review, the facility failed to monitor the use of insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) and anticoagulant therapy (a medical treatment using drugs called blood thinners to prevent or treat dangerous blood clots [thrombi] by slowing the blood's clotting process, stopping existing clots from growing, and preventing new ones from forming) for two (2) of 15 sampled residents (Residents 1, and 32) as indicated on the residents' care plan by failing to monitor: 1. Resident 1 for signs and symptoms of hypoglycemia (an abnormally low level of sugar [glucose] in the blood) and hyperglycemia (a condition where the blood glucose [sugar] levels are abnormally high), while on Insulin Lispro (Humalog, a fast-acting insulin) from 12/21/2025 to 1/23/2026. 2. a. Resident 32 for signs and symptoms of hypoglycemia and hyperglycemia while on Insulin Lispro from 11/18/2025 up to 11/23/2026. 2. b. Resident 32 for signs and symptoms of bleeding for the use of Enoxaparin Sodium Injection (Lovenox, is an anticoagulant, also known as a blood thinner, that slows the body's normal clotting process and reducing risk of deep vein thrombosis [DVT, a condition in which harmful blood clots form in the blood vessels of the legs]) from 11/18/2025 to 1/23/2026. This deficient practice had the potential for Residents 2 and 32 to experience episodes of hypoglycemia, hyperglycemia, and bleeding without proper monitoring while on insulin, which may result in harm, hospitalization, and death.Findings:1. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 1's diagnoses included type 2 diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing), right leg cellulitis (a bacterial infection that enters the skin and tissue through a wound), lumbar spine spondylosis (a common condition that refers to age related wear and tear affecting the discs and joints of the lower back over time), and lymphedema (swelling that occurs when the lymphatic system [part of the body's immune and drainage network] cannot properly remove excess fluid, causing it to accumulate in tissues leading to persistent swelling, often in the arms or legs). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 12/29/2025, the MDS indicated Resident 1 had intact cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 1 needed setup or clean-up assistance (Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity) in eating and oral hygiene. The MDS also indicated Resident 1 needed supervision or touching assistance (helper provides verbal cues and/or touching/ steadying and/or contact guard assistance as resident completes activity) toileting hygiene, shower/ bathe self, upper body dressing, roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, and chair/ bed-to-chair transfer, toilet transfer, tub / shower transfer, walk 10, 50, and 150 feet. During a concurrent interview and record review on 01/23/2026 8:10 AM with MDS Nurse (MDSN), Resident 1's Physician Orders (PO) dated 12/21/2025 was reviewed. The PO indicated Humalog Injection Solution 100 units per milliliter (ML, measure of volume) Inject subcutaneous (SQ, a shot that delivers medicine into the fatty tissue layer just under the skin, above the muscle, using a short, small needle for slow, steady absorption) three times a day for DM II. Inject per sliding scale (method of adjusting medication doses, most commonly insulin, based on the resident's blood glucose level [amount of sugar present in the blood at a given time]):If below 80= If conscious give four (4) ounces (oz, unit of weight) of juice. If unconscious, Give Glucagon (a hormone that raises blood sugar) 1 milligram (mg, a unit of weight/mass) intramuscular injection (IM, is the injection of a medication into a muscle); Notify Physicianif 81 to 150 = 0;151 to 200 = 2 units;201 to 250 = 4 units;251 to 300 = 6 units;301 to 350 = 8 units;351 to 400 = 10 unitscall MD IF Blood Sugar was greater than (>) 400MDSN stated Resident 1 did not have an order to monitor for signs and symptoms (s/s) of hypoglycemia and hyperglycemia while using insulin; therefore, there was no documented evidence that Resident 1 was monitored for these symptoms. MDSN stated if it was not documented, then it was not done. MDSN stated it was important for Resident 1 to be monitored for the s/s of hypoglycemia and hyperglycemia because the worst possible outcome during an episode of hypoglycemia is a diabetic coma (a medical emergency caused by a blood sugar level that was too low or too high). MDSN added, if Resident 1 exhibits symptoms of hyperglycemia, the most serious consequence could be metabolic acidosis (a condition in which there is too much acid in the body fluids), and the resident might need to be transferred to the hospital. During a concurrent interview and record review on 1/23/2026 at 8:15 AM with MDSN, Resident 1's Care Plan (CP) for diabetes mellitus dated 1/9/2026 was reviewed. The CP indicated Resident 1 had diabetes mellitus and was at risk for hypoglycemia or hyperglycemia reaction. MDSN state the CP interventions should have included monitoring Resident 1 for s/s of hypoglycemia or hyperglycemia. During an interview on 1/23/2026 at 4:57 PM with Pharmacist 2, Pharmacist 2 stated that licensed facility staff should know the s/s of hypoglycemia and hyperglycemia when residents are using insulin. They should document monitoring for these s/s in the residents' records. Pharmacist 2 stated this should be included in the resident's care plan, documented in the progress notes, and the physician should always be notified according to the physician's order. 2. During a review of Resident 32's admission Record, the admission Record indicated Resident 32 was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 32's diagnoses included DM II, bilateral knee osteoarthritis (a type of arthritis that happens when cartilage in the joints wears down), obesity (a condition marked by excess accumulation of body fat), and hypertension (high blood pressure), During a review of Resident 32's MDS, dated [DATE], the MDS indicated Resident 32's cognitive skills for daily decision making were intact. The MDS indicated Resident 32 needed substantial/ maximal assistance (helper does more than half the effort. helper lifts, holds trunk or limbs, and provides more than half the effort) toileting hygiene, shower/bathe self, lower body dressing, putting on/ taking off footwear roll left and right, sit - to lying, lying to sitting on side of bed, sit to stand, and chair/ bed-to-chair transfer, toilet transfer, and walk 10 feet. The MDS also indicated Resident 32 received 2 insulin injections during the last 7 days. a. During a concurrent interview and record review on 1/23/2026 at 8:51 AM with MDSN, Resident 32's PO, dated 11/18/2025, was reviewed. The PO indicated, Insulin Lispro Injection Solution 100 units per ML, inject subcutaneously before meals and at bedtime for DM II. Inject as per sliding scale:If 0 to 80 =If conscious, give 4 oz of juice. If unconscious, give Glucagon 1mg IM times 1. Notify Physician.81 to 149 = 0;150 to 199 = 1 unit;200 to 249 = 2 units;250 to 299 = 3 units;300 to 349 = 4 units;350 to 400 = 5 unitsMDSN stated Resident 32 did not have an order to monitor for s/s of hypoglycemia and hyperglycemia while using insulin; therefore, there was no documented evidence that Resident 32 was monitored for these symptoms. MDSN stated if it was not documented, then it was not done. During a concurrent interview and record review on 1/23/2026 at 8:53 AM with MDSN, Resident 32's CP for diabetes mellitus dated, 2/2/2025 was reviewed. The CP indicated Resident 32 was at risk for hypoglycemia or hyperglycemia.The CP interventions indicated the following: Monitor/document/report as needed (PRN) signs and symptoms of hyperglycemia: increase thirst, headaches, trouble concentrating, blurred vision, frequent urination, fatigue, and weight loss. Monitor/document/report PRN signs and symptoms of hypoglycemia: sweating, tremor, increased heart rate (tachycardia), pallor (skin paleness), nervousness, confusion, slurred speech, lack of coordination, staggering gait.MDSN stated Resident 32's CP interventions for monitoring hypoglycemia and hyperglycemia were not followed and implemented because there was no documentation that the staff monitored Resident 32. During a concurrent interview and record review on 1/23/2026 8:55 AM with MDSN, Resident 32's Nurses' Progress Notes (NPN), dated 11/18/2025 to 11/30/2025 were reviewed. MDSN stated that there was no documentation indicating the licensed nurses monitored Resident 32 for hypoglycemia and hyperglycemia. MDSN added the licensed staff did not properly monitor Resident 32. During a concurrent interview and record review on 01/23/2026 at 9:00 AM with MDSN, Resident 32's Nurses' Progress Notes (NPN), dated 1/1/2026 to 1/23/2026, were reviewed. MDSN stated that there was no documentation showing staff monitored Resident 32 for s/s of hypoglycemia and hyperglycemia. MDSN also stated that if there was no documentation of monitoring for these s/s, staff were not aware of the residents' condition and would not be able to provide quality care. During an interview on 1/23/2026 at 4:52 PM with Pharmacist 1, Pharmacist 1 stated that the facility usually has a protocol when a resident is taking insulin which is to monitor for s/s of hypoglycemia and hyperglycemia. During a review of the facility's undated policy and procedure (P&P) titled, Diabetes Clinical Protocol, the P&P indicated, the staff and provider will monitor for and manage hypoglycemia appropriately. Monitoring is included as part of the plan of care. The staff and provider will monitor for and manage hyperglycemia appropriately. Monitoring is included as part of the plan of care. b. During a concurrent interview and record review on 1/23/2026 at 8:51 AM with MDSN, Resident 32's PO, dated 11/18/2025, was reviewed. The PO indicated Enoxaparin Sodium Solution 40 mg/ 0.4 ml. Inject 40 mg subcutaneously one time a day for blood clotting prevention. MDSN stated Resident 32 did not and should have had an order to monitor bleeding, for bruises, and hematoma (a localized collection of blood outside of the blood vessels) because the resident was prone to it due to use of Lovenox. During a concurrent interview and record review on 1/23/2026 at 9:09 AM with MDSN, Resident 32's CP on Anticoagulant therapy dated 11/19/2025 was reviewed. The CP Interventions indicated the following: Administer anticoagulant medications as ordered by physicians. Monitor for side effects and effectiveness every shift. Monitor/document/report PRN adverse reactions of Anticoagulant therapy: blood tinged or red blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, shortness of breath, loss of appetite, sudden changes in mental status, significant or sudden changes in vital signs. MDSN stated Resident 32's CP interventions were not followed and implemented because there was no documented evidence in Resident 32's chart. During a concurrent interview and record review on 1/23/2026 at 9:11AM with MDSN, Resident 32's NPN, dated 11/18/2025 to 11/30/2025 was reviewed. MDSN stated there was no documentation that Resident 32 was monitored for signs and symptoms of bleeding in the nurses' progress notes. During a concurrent interview and record review on 1/23/2026 at 9:20AM with MDSN, Resident 32's NPN, dated 1/1/2026 to 1/23/2026 was reviewed. MDSN stated there was no documentation that Resident 32 was monitored for signs and symptoms of bleeding which means the licensed staff were not checking Resident 32 while on anticoagulant therapy. During an interview on 1/23/2026 at 4:57 PM with Pharmacist 2, Pharmacist 2 stated when a resident is on anticoagulant therapy, the licensed staff should monitor the resident for bleeding. Pharmacist 2 stated the licensed staff should document in the resident's chart the specific symptoms of bleeding being monitored like nosebleeds, gum bleeding, and signs of internal bleeding such as dark stools or reddish- colored urine).

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of two (2) of six (6) sampled residents (Resident 10 and 17) observed for medication administration as indicated on the facility policy and physician's order when:Resident 17's medications were not administered within 60 minutes of scheduled time of 9 AM on 1/22/2026.Resident 10's medications were not administered within 60 minutes of scheduled time of 9 AM on 1/22/2026.This deficient practice had the potential to prevent Residents 10 and 17 from obtaining the therapeutic level of their medications (a range in the blood that is medically effective but not dangerous), which could lead to complications and negatively impacting the residents' overall well-beingCross reference: F759Findings:1. During a review of the admission Record, the admission Record indicated Resident 17 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 17's diagnoses included were benign prostatic hyperplasia (BPH, health issue with urination, problems like a weak stream, difficulty starting to pee, and frequent urination), dementia (a progressive state of decline in mental abilities), and hypertensive heart disease (long-term high blood pressure) with heart failure (the heart cannot pump).During a review of Resident 17's Minimum Data Set (MDS - a resident assessment tool) dated 7/12/2025, the MDS indicated Resident 17 had modified independence (some difficulty in new situations only) with cognitive (thought process and ability to reason or make decisions) skills for daily decision making. The MDS indicated Resident 10 was dependent (helper does all the effort) on staff for toileting hygiene, shower, upper and lower body dressing, and putting on/taking off footwear. The MDS indicated Resident 10 required substantial/maximal assistance (helper does more than half the effort) from staff with eating, shower and personal hygiene.During a review of Resident 17's Order Summary Report, dated 1/21/2026, the Order Summary Report indicated the following orders:Ascorbic acid (vitamin C, essential, water-soluble nutrient found in fruits and vegetables that the human body cannot produce on its own) oral tablet, give 1 tablet by mouth two times a day for supplement, ordered on 12/11/2025. Bethanechol chloride (used to treat urinary retention) oral tablet 10 milligrams (mg, unit of measurement), give 1 tablet by mouth three times a day for urine retention, ordered om 12/11/2025. Carbidopa-Levodopa (medication used to treat Parkinson's disease [a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements] symptoms like tremors, stiffness, and slowness) oral tablet 25-100 mg, give 1 tablet by mouth one time a day for Parkinson's disease, ordered om 12/11/2025. Docusate sodium oral tablet 100 mg, give 1 tablet by mouth two times a day for bowel management, hold for loose stools, ordered on 1/21/2026. Escitalopram oxalate (medication used to treat depression) oral tablet 10 mg, give 1 tablet by mouth one time a day for depression manifested by verbalization of sadness, ordered on 12/11/2025. Lactobacillus oral tablet, give 1 capsule by mouth, once a day for probiotic (bacteria and yeasts, that provide health benefits when consumed), ordered on 1/21/2026. Furosemide (medication used treat fluid retention) oral tablet 40 mg, give 1 tablet by mouth two times a day for congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), hold if systolic blood pressure (SBP, the top/higher number in a reading, representing the pressure when your heart beats and pumps blood out) is less than 110 or heart rate of less than 60, ordered on 12/11/2025.During a medication administration observation on 1/22/2026 at 11:03 AM, with LVN 2, LVN 2 prepared and administered the following six (6) medications to Resident 17: Ascorbic acid oral tablet, 1 tablet. Bethanechol chloride oral tablet 10 mg, 1 tablet. Carbidopa-Levodopa oral tablet 25-100 mg, 1 tablet Docusate sodium oral tablet 100 mg, 1 tablet. Escitalopram oxalate oral tablet 10 mg, 1 tablet. Lactobacillus oral tablet, 1 capsule.During an interview on 1/22/2026 at 11:26 AM, LVN 2 stated that he administered Resident 17's medications, which were scheduled for 9 AM, late-after the one-hour window-because he was busy with another resident.2. During a review of the admission Record, the admission Record indicated Resident 10 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 10's diagnoses included diabetes mellitus (high blood sugar), encounter for attention to gastrostomy (G-tube, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), and lack of coordination.During a review of Resident 10's (MDS - a resident assessment tool) dated 1/2/2026, the MDS indicated Resident 10 had severely impaired cognitive skills for daily decision making. The MDS indicated Resident 10 was dependent on staff for eating, oral hygiene, toileting hygiene, shower, upper and lower body dressing, putting on/taking off footwear and personal hygiene.During a review of Resident 10's Order Summary Report, dated 1/21/2026, the Order Summary Report indicated the following orders:Ativan (medication used as a powerful sedative and calming agent) oral tablet 0.5 mg, give 1 tablet via G-Tube every 12 hours for unspecified anxiety (a natural human feeling of fear, dread, or intense worry) disorder manifested by constantly yelling for no apparent reason, ordered on 10/3/2025.Baclofen (medication used as muscle relaxant) oral solution 5 mg/5ml, given 5 ml via G-tube one time a day for muscle relaxants, ordered on 1/19/2025.Benztropine mesylate (medication used to treat movement disorders and muscle spasms) oral tablet 0.5 mg, give 1 tablet via G-Tube every 12 hours for extrapyramidal (Involuntary or uncontrollable muscle movements and body stiffness) and movement disorder, ordered on 10/3/2025.Escitalopram oxalate oral solution 5 mg/5ml, give 10 ml via G-Tube one time a day for depression manifested by constant crying for no apparent reason, ordered on 10/3/2025.Esomeprazole magnesium (medication that works by reducing the amount of acid produced in the stomach) oral packet 40 mg, give 1 packet via -tube, two times a day for Gastroesophageal Reflux Disease (GERD, a chronic condition where stomach acid frequently flows back up). Mix contents of 1packet with 15 ml of water and leave 2-3 minutes to thicken. Stir and administer within 30 minutes of mixing, ordered on 10/3/2025.Senna (plan-based medicine to treat constipation) oral tablet 8.6 mg, give 1 tablet via G-Tube two times a day for bowel management, hold for loose stool, ordered on 10/3/2025Zyprexa (olanzapine, medication used to treat serious mental health conditions) oral tablet 2.5 mg. Give 1 tablet via G-Tube two times a day for schizophrenia (a mental illness that is characterized by disturbances in thought) manifested by striking out at staff during activities of daily living. Ordered on 10/3/2025.During a medication administration observation on 1/22/2026 at 12:44 PM, RNS 4 prepared and administered the following six (7) medications to Resident 10:Ativan oral tablet 0.5 mg, 1 tablet.Baclofen oral solution 5 mg/5ml, 5 ml.Benztropine mesylate oral tablet 0.5 mg, 1 tablet.Escitalopram oxalate oral solution 5 mg/5ml, 10 ml liquid solution.Esomeprazole magnesium oral packet 40 mg, 1 packet.Senna oral tablet 8.6 mg, 1 tablet.Zyprexa (olanzapine) oral tablet 2.5 mg. 1 tablet.During an interview on 1/23/2026 at 11:27 AM, RNS 3 stated failing to administer medication to a resident as ordered by the physician can lead to medical complications, possibly resulting in hospitalization. RNS 3 stated the facility's morning medication administration time is scheduled for 9 AM, and medications may be administered one hour before or after 9 AM. RNS 3 further stated if medications are administered late or early, the licensed nurse must notify the physician and document the reason for the delay in the resident's progress notesDuring an interview on 1/23/2026 at 12:11 PM, LVN2 stated on 1/22/2026, Resident 17's 9 AM medications were administered outside the one-hour window. LVN 2 stated when administering medications to his assigned residents, he takes time to check their vital signs, such as blood pressure, and pays attention to residents who want to speak with him. LVN 2 stated he should have delegated the administration of medications for other residents who had not received their 9 AM doses to another licensed nurse in the facility, such as the RN Supervisor, Director of Staff Development, Infection Preventionist Nurse, MDS Nurse, or Director of Nursing (DON). LVN 2 stated it is important to administer medications on time and as ordered by the physician to ensure efficacy and avoid possible adverse reactions or side effects that the resident may experience.During an interview on 1/23/2026 at 7 PM, the DON stated not following a physician's order constitutes a medication error. The DON confirmed that LVN 2 administered Resident 17's 9 AM medications late on 1/22/2026 and that RNS 4 also administered Resident 10's 9 AM medications late on the same day. The DON stated medications may be administered one hour before or after the scheduled time but should not exceed that window, as doing so is considered a medication error. The DON added when LVN 2 and RNS 4 were having difficulty administering medications within the allotted time, they should have asked for assistance so another licensed nurse could help. The DON stated, If medications are not administered on time, for example, anti-anxiety medications, it can affect the mood and behavior of residents, which can impact their activities of daily living (ADLs).The DON also added failing to administer medication as ordered by the physician can lead to medical complications, possibly resulting in hospitalization.During a review of facility's Policy and Procedure (P&P) titled, Administering Medications, revised in April 2019, the P& indicated medications are administered in a safe and timely manner, and as prescribed. It indicated medications are administered in accordance with prescriber orders, including any required time frame. It also indicated medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders) or ordered by the physician.

Based on observation, interview, and record review, the facility failed to ensure five (5) of five sampled residents (Resident 2, 6, 35, 10, and 31) reviewed for pressure ulcer (PU- injury to skin and underlying tissue resulting from prolonged pressure on the skin) were provided necessary treatment and services to prevent formation of PU and/ or promote healing of PU in accordance with the facility's policy and procedure and physician's order by failing to: Ensure Resident 2's low air loss mattress (LALM-are designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown) was set according to the resident's weight. On 1/21/2026, Resident 2 was observed with the LALM set at 350 pounds (lbs.- unit of measurement).Ensure Resident 6's LALM was set according to the resident's weight. Resident 6 was observed with the LALM set in between 265 to 400 lbs. on 1/21/2026 8:12 AM.Completely assess and document Resident 35's sacrococcyx (bones at the very bottom of your spine, with the sacrum being a large, triangular bone connecting to the pelvis, and the coccyx [tailbone] being a smaller, fused bone just below it, providing attachment points for muscles and ligaments and acting as a shock absorber when sitting) Stage 3 (a severe, full-thickness wound extending through the skin to expose subcutaneous fat, appearing as a deep crater, often with slough or rolled edges) PU when the resident was readmitted to the facility on [DATE].Ensure Resident 10's LALM was set according to the resident's weight. On 1/20/2026, Resident 6 was observed with the LALM set at 300 lbs.Ensure Resident 31's LALM was set according to the residents' weight. On 1/20/2026, Resident 31 was observed with the LALM set at 320lbs. These deficient practices had the potential for Resident 6, 10 and 31 to develop new PU and the potential for Resident 2 and 35 to experience worsening of PU.Findings: 1.During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE], Resident 2's diagnoses included anemia (low red cells), muscle weakness, and spondylolisthesis (one of the small bones in the spine slips out of its normal position). During a review of Resident 2's Minimum Data Set (MDS, a resident assessment and tool) dated 12/26/2025 the MDS indicated Resident 2 's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making were intact. The MDS also indicated Substantial/maximal assistance (helper does more than half the effort. helper lifts or holds trunk or limbs and provides more than half the effort) on roll left and right (the ability to roll from lying on back to left and right side and return to lying on back on the bed), sit to lying (the ability to move from sitting on side of bed to lying flat on the bed). The MDS indicated Resident 2 was at risk of developing pressure ulcers/injuries. The MDS indicated Resident 2 has unhealed stage 2 ulcer (partial thickness of loss of dermis presenting as a shallow open ulcer with red or pink wound bed, without slough or bruising). The MDS also indicated skin and ulcer/ injury treatment included pressure reducing device for bed. During a record review of Resident 2's Braden Scale (an assessment tool used for predicting the risk for developing pressure sores) dated 9/24/2025, it indicated Resident 2' is at risk for developing PU. During a record review of Resident 2's Care Plan, date initiated 9/26/2025, revised on 12/11/2025, the Care Plan indicated Resident 2 has actual impairment to skin integrity at right inner buttock stage 2. The care plan also indicated LALM to bed and set at resident weight for firmness and alternating, float. The Care Plane also indicated to check mattress every shift for proper setting and function may adjust to resident comfort level. During a record review of Resident 2's Order Summary Report dated 1/21/2026, the Order Summary Report indicated a physician's order dated 11/7/2025 for Low Air Mattress to bed. Set at resident weight for firmness and alternating, float. During observation on 1/21/2026 at 7:59 AM in Resident 2's room, Resident 2's LALM setting was set at 350 lbs. During a concurrent observation in Resident 2's room, interview and record review on 1/21/2026 at 3:22 PM with the Registered Nurse Supervisor (RNS 1), Resident 2's weight dated 1/5/2026 entered at 3:46 AM was reviewed. The record indicated Resident 2 weighed 141 lbs. RNS 1 stated the LALM setting was set at 350 lbs. but should have been set to 150 lbs. since Resident 2 weighed 141 lbs. on 1/5/2026. RNS 1 also stated, when the LALM was not in the correct setting, it defeats its purpose and can cause more harm to Resident 2 than prevent harm/ development of new PU and worsening of PU. During an interview on 1/21/2026 at 3:52 PM with the Director of Nursing (DON), the DON stated 350 lbs. setting for Resident 2 was too firm, and it can contribute to the worsening of PU. Resident 2's LALM setting should be set 150 lbs. 2. During a review of Resident 6's admission Record, the admission Record indicated Resident 6 was originally admitted to the facility on [DATE] and was re admitted on [DATE]. The admission record indicated Resident 6's diagnoses included muscle weakness, acute kidney failure (the sudden, rapid loss of kidney function), scoliosis (progressive, three-dimensional lateral curvature of the spine). During a record review of Resident 6's Braden Scale dated 1/2/2026 indicated Resident 6 is at risk for developing PU. During a review of Resident 6's MDS dated [DATE], the MDS indicated Resident 6 's cognitive daily decision making was intact. The MDS also indicated Resident 6 was dependent (helper does all the effort. Residents do none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity) on roll left and right, lying to sitting on side of bed. The MDS indicated Resident 6 was at risk of developing PU. During a record review of Resident 6's Order Summary Report dated 1/22/2026, the Order Summary Report indicated a physician's order dated 12/17/2025 for Low Air Mattress to bed. Set at resident weight for firmness and alternating, float. During a record review of Resident 6's Care Plan, revised on 10/15/2025, the Care Plan indicated Resident 6 has potential to skin integrity/breakdown due to impaired mobility, incontinence (involuntary loss of urine or stool). The care plan interventions indicated LALM to bed and set at resident weight for firmness and alternating, float. The care plan also indicated to check mattress every shift for proper setting and function and provide LALM for skin maintenance. During observation on 1/21/2026 at 8:12 AM at Resident 6's room observe LALM setting was in-between 265 lbs. to 400 lbs. During concurrent observation on 1/21/2026 at 12:52 PM with License Vocational Nurse (LVN 1) at Resident 6's room, LVN 1 stated the LALM was set in between 265 lbs. to 400 lbs. During a concurrent interview and record review on 1/22/2026 at 2:50 PM with RNS 1, Resident 6's weight dated 1/16/2026 entered at 2:34 PM was reviewed. The record indicated Reisdent 6 weighed 207 lbs. on 1/16/2026. RNS 1 stated the LALM setting was set in between 265 lbs. to 400 lbs., and it should have been set between 180 lbs. to 265 lbs. since Resident 6 weight was 207 lbs. on 1/16/2026. 3. During a review of Resident 35's admission Record, the admission Record indicated Resident 35 was originally admitted to the facility on [DATE] and was re admitted on [DATE]. The admission record indicated Resident 35's diagnoses included diabetes mellitus (a disorder in which the body does not produce enough or respond normally to insulin [a hormone released from the pancreas that controls the amount of glucose in the blood], causing blood sugar [glucose] levels to be abnormally high) pressure ulcer of sacral region, stage 3 (full-thickness wound extending through the skin into the subcutaneous fat layer [deepest layer of your skin], often appearing as a deep, crater-like, and painful, open wound), hemiplegia (complete paralysis, muscle stiffness, and inability to move one side of the body) and hemiparesis (complete paralysis, muscle stiffness, and inability to move one side of the body). During a record review of Resident 35's Braden Scale dated 12/29/2025 indicated Resident 35 is at risk for developing PU. During a review of Resident 35's MDS dated [DATE], the MDS indicated Resident 35 's cognitive skills for daily decision making were moderately impaired. The MDS also indicated Resident 35 was dependent on roll left and right, sit to lying, lying to sitting on side of the bed. The MDS indicated Resident 35 was at risk of developing PU. The MDS indicated Resident 35 has one Stage 3 pressure ulcer (location not indicated). During a concurrent interview and record review on 1/23/2026 9:52 AM with the DON, Resident 35's medical record titled Admit/Readmit Data Collection and Baseline dated 12/29/2025 timed at 4:20 PM was reviewed. Resident 35's admission assessment indicated resident had a healing stage 3 pressure ulcer, it did not include documentation of the size of the pressure ulcer. The DON stated a complete description of the pressure ulcer should have been documented to establish accurate baseline including the size and whether there is drainage or foul odor. During a concurrent interview and record review on 1/23/2026 at 12:25 with the DON and MDS Nurse (MDSN), Resident 35's medical records dated 12/29/2025 to 1/12/2026 were reviewed. The DON stated Resident 35 was admitted at the facility on 12/29/2025 and the only wound assessment for Resident 35 following the admission assessment (12/29/2025) was completed by the Nurse Practitioner (NP) on 1/13/2026. The DON stated Resident 35's medical records did not have documented evidence of the weekly wound assessments or measurements that were completed for Resident 35. The DON also stated the licensed nurses need more education regarding the need for assessing the resident's wound condition on a weekly basis and that during wound assessment the measurement and description of the wound needs to be documented to know the improvement or decline of the wound. During a concurrent interview and record review on 1/23/2026 4:49 PM with LVN 1 of Resident 35's care plan, LVN 1 stated the care plan initiated on 1/19/2026 indicated Resident 35 has sacrococcyx, moisture-Associated Skin Damage (MASD- caused by prolonged exposure to a source of moisture such as urine, stool, sweat, wound drainage, saliva, or mucus). related to fragile skin, decrease mobility, and incontinence. LVN 1 stated the care plan intervention indicated documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. LVN 1 stated there was no documented evidence that an assessment or monitoring was done for Resident 35's wound on the sacrococcyx. During a concurrent interview and record review on 1/23/2026 4:52 PM with LVN 1, LVN 1 stated the LALM operational manual titled Brand 1 Alternating Pressure Low Air Loss Mattress Replacement System date revised 3/22/2021, it indicated to determine the patient's weight and set the control knob to that weight setting on the control unit. LVN 1 also stated the P&P and operational manual was not followed. During a review of facility's Policy and Procedures (P&P) titled Charting and Documentation date revised 7/2017, the P&P indicated all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The P&P indicated documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. 4. During a review of the admission Record indicated Resident 10 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that includes diabetes mellitus (high blood sugar), encounter for attention to gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), and lack of coordination. During a review of Resident 10's MDS, dated [DATE], indicated Resident 10 had severely impaired cognitive (thought process and ability to reason or make decisions) skills for daily decision making. The MDS indicated Resident 10 was dependent (helper does all the effort) from staff for eating, oral hygiene, toileting hygiene, shower, upper and lower body dressing, putting on/taking off footwear and personal hygiene. The MDS also indicated Resident 10 was dependent from staff from rolling left and right (the ability to roll from lying on back to left and right side, and return to lying on back on the bed), sit to lying (the ability to move from sitting on side of bed to lying flat on the bed), and lying to sitting on side of bed (the ability to move from lying on the back to sitting on the side of the bed and with no back support). During a review of Resident 10's Order Summary Report, dated 1/21/2026, indicated an order of low air loss mattress to bed and set at resident weight for firmness. The order summary report also indicated to check mattress for proper setting and function, every shift for skin management with order date of 10/27/2025. During an observation of Resident 10's low air loss mattress on 1/20/2026 at 9:27 AM, the mattress was set to 300 pounds lbs. During an observation of Resident 10's low air loss mattress on 1/21/2026 at 3:33 PM, the mattress was set to 350 lbs. During a concurrent record review and interview on 1/21/2026 at 4:37 PM with MDS nurse (MDSN), Resident 10's electronic medical records dated 10/27/2025 to 1/21/2026 were reviewed. MDSN stated Resident 10's latest weight on 1/5/2026 is 112 lbs. MDSN stated Resident 10's LALM is for skin maintenance, as ordered on 10/27/2025. MDSN stated, the facility staff) set the LALM according with the resident's weight. MDSN also stated the licensed nurses must do their rounds when they come in and make sure the LAL mattress setting of the resident is set correctly according the resident's weight. MDSN also added it is important to follow the order to ensure LALM is benefiting Resident 10 and will not cause new skin problems. During a concurrent observation and interview on 1/21/2026 at 4:42 PM with MDSN, Resident 10's LALM was observed. MDSN verified that Resident 10's LALM is currently set at 350 and it was not the correct setting for Resident 10. During an interview on 1/22/2026 at 8:33 AM with Treatment Nurse (TXN) 1, he stated using a low air loss mattress was important for Resident 10 because the resident is not ambulatory. TXN 1 stated, it is for preventative measure to ensure the Resident 10 will not develop any pressure related skin breakdown. During a review of Resident 31's admission Record, the admission Record indicated Resident 31 was admitted to the facility on [DATE] and re-admitted on [DATE]. The admission record indicated Resident 31's diagnoses included metabolic encephalopathy (ME, occurs when problems with your metabolism cause brain dysfunction), hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body)following cerebral infarction (refers to damage to tissues in the brain due to a loss of oxygen to the area) affecting left non-dominant side. During a review of Resident 31's MDS dated [DATE], the MDS indicated Resident 31 had moderately impaired cognitive skills for daily decision making. The MDS indicated Resident 31 was dependent in eating, oral hygiene, toileting hygiene, shower/ bathe self, upper and lower body dressing, putting on/ taking off footwear, roll left and right, sit to lying, lying-to-sitting on the side of the bed, sit-to stand, and chair/ bed-to-chair transfer. The MDS also indicated Resident 31 was at risk for pressure ulcers (PU) and using pressure relieving devices for bed. During a review of Resident 31's Physician's Order (PO) dated 12/15/2025, the PO indicated, LALM to bed. Set at resident weight for firmness. Check mattress every shift for proper setting and function May adjust to resident comfort level every shift. During a review of Resident 31's Care Plan (CP) revised on 12/6/2025, the CP indicated Resident 31's wound management interventions included Low Air Mattress to bed, set at resident weight for firmness, and check mattress for proper setting and function every shift. During a review of Resident 31's Braden Scale Assessment (BSA) dated 10/7/2024 was reviewed. The BSA indicated Resident 31 was at high risk for developing pressure ulcers. During an observation and record review on 1/20/2026 at 9:15 AM inside Resident 31's room, Resident 31 was lying in bed and asleep. Resident 31's LALM was set up at 320 mmHg. Resident 31's weight and vital signs for the month of January 2026 were reviewed, Resident 31's weight on 1/5/2026 was 172.0 lbs. During an observation on 1/21/2026 at 8:24 AM inside Resident 31's room, Resident 31 was lying in bed sleeping. Resident 31's LALM was set up at 190 mmHg. During a concurrent observation and interview on 1/22/2026 at 7:36 AM inside Resident 31's room, Resident 31 was lying in bed. LALM was set up at 190 mmHg. Resident 31 stated My bed is hard. It hurts my back and buttocks During a concurrent interview and record review on 1/22/2026 at 8:01 AM with LVN 2, Resident 31's Physician order dated 12/15/2026 was reviewed. LVN 2 stated the physician order indicated Low Air Mattress to bed and set at resident weight for firmness. LVN 2 stated, Resident 31's current weight is 172 lbs. and the LALM setting of Resident 31 should have been set to 170 up to 180 lbs. During a concurrent observation and interview on 1/22/2026 at 8:02 AM with LVN 2 inside Resident 31's room, Resident 31's LALM was set up on 190mmHg. LVN 2 stated LALM was set up on 190-200 mmHg, which was a bit high and too firm. LALM in a very high settings are going to be too firm for Resident 31 and place the resident at risk for skin breakdown During an interview on 1/22/2026 at 8:04 AM with LVN 2, LVN 2 stated If the LALM was set up on 320 mmHg, that was too high, too firm or too hard for Resident 31. Resident 31 had a history of pressure ulcer, and there is potential for Resident 31 to have a skin breakdown. During a review of facility's P&P titled Pressure Relieving Devices Policy undated, the P&P indicated to provide guidance on the proper selection, use, and monitoring of pressure relieving devices to prevent and manage pressure injuries in residents at risk. The P&P indicated Low-air-loss mattress reduces moisture and shear in high-risk residents. The P&P also indicated under usage and maintenance the devices must be properly set up and positioned according to manufacturer instructions.

Based on observation, interview, and record review, the facility failed to maintain a safe, clean, comfortable sanitary and home-like environment for four (4) of 4 sampled residents (Resident 4,6,19 and 35) reviewed for environment, by failing to ensure:The air vent (openings in buildings for air passage, essential for ventilation, air circulation, and maintaining indoor air quality) including the surrounding frame located on top of Resident 4's head of the bed does not have dust build up.The bedside table of Resident 6 was not chipped off exposing the interior wood.The bed control for Residents 6 and 19 does not have crack and rough edges.The overhead light of Resident 19 was not cracked.The television (TV) of Resident 35 was functioning. These deficient practices caused an unsanitary and unsafe environment and had potential for Residents 4, 6, and 19 and staff to be placed at risk of injury. In addition, it a potential to negatively affect Resident 35's well-being and quality of life.Findings:1.During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was initially admitted to the facility on [DATE] with diagnosis which dementia (progressive brain disorder that slowly destroys memory and thinking skills), diabetes mellitus (a disorder in which the body does not produce enough or respond normally to insulin [a hormone released from the pancreas that controls the amount of glucose in the blood], causing blood sugar [glucose] levels to be abnormally high), and chronic obstructive pulmonary disease (COPD, disease that causes obstructed airflow from the lungs) During a review of Resident 4's Minimum Data Set (MDS, a resident assessment tool), dated 12/10/2025, the MDS indicated Resident 4's cognitive skills (processes of thinking and reasoning) for daily decision making was severely impaired (never/rarely made decisions). The MDS also indicated Resident 4 needed partial/moderate assistance on personal hygiene (the ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face and hands (excluding baths, showers, and oral hygiene). During an observation on 1/20/2026 at 8:18 AM in Resident 4's room, Resident 4 was in bed, and above Resident 4's head of the bed, the air vent was visibly coated with dust including the surrounding frame. During a concurrent observation in Resident 2's room and interview on 01/21/2026 at 4:14 PM with the Director of Nursing (DON), the DON stated Resident 4's air vent was covered with dust buildup. The DON also stated Resident 4's air vent with dust buildup was not acceptable, it creates fire risk, and it was not good for resident's health. During an interview on 1/23/2026 at 7:50 AM, with the Maintenance Supervisor (MS), the MS stated cleaning of Resident 4's air vent was not cleaned. The MS also stated air vents should be cleaned on daily basis to ensure the air vent can properly filter the air, especially for residents on breathing treatments to ensure the residents receive clean fresh air. 2.During a review of Resident 6's admission Record, the admission Record indicated Resident 6 was originally admitted to the facility on [DATE] and was re admitted on [DATE], Resident 6's diagnoses included muscle weakness, acute kidney failure (the sudden, rapid loss of kidney function), and scoliosis (progressive, three-dimensional lateral curvature of the spine). During a review of Resident 6's MDS dated [DATE] the MDS indicated Resident 6 's cognitive daily decision making was intact. The MDS also indicated Resident 6 was Dependent (helper does all the effort. Residents does none of the effort to complete the activity) on eating (the ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident), Shower/bathe self (the ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair), Roll left and right (the ability to roll from lying on back to left and right side, and return to lying on back on the bed). During an observation in Resident 6's room on 1/20/2026 at 8:41 AM, observed Resident 6's bedside table had area that was chipped off and with rough wood exposed. During a concurrent observation and interview on 1/21/2026 at 12:55 PM with the Director of Staff and Development (DSD), DSD stated Resident 6's bedside table was chipped off, with rough wood exposed, and this can cause skin tears to Resident 6 and staff. 3. During an observation on 1/20/2026 at 8:41 AM in Resident 6's room, Resident 6's bed control was observed to be visibly damaged, with chipped and cracked edges around the casing. During a concurrent observation and interview on 1/21/2026 at 12:56 PM in Resident 6's room with the DSD, Resident 6's bed control was broken and with rough edges. The DSD stated Resident 6's bed control was broken, chipped around the edges, and with rough edges that can cause skin tears to Resident 6 and staff. 4. During a review of Resident 19's admission Record, the admission Record indicated Resident 19 was admitted on [DATE] with diagnoses that included muscle weakness, diabetes mellitus, heart failure (a lifelong condition in which the heart muscle can't pump enough blood to meet the body's needs for blood and oxygen). During a review of Resident 19's MDS dated [DATE], the MDS indicated Resident 19 's cognitive daily decision making was intact. The MDS also indicated Resident 19 was set up or clean-up assistance (helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity) with eating and supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with oral hygiene and personal hygiene. During concurrent observation and interview on 1/21/2026 at 12:58 PM with the DSD in Resident 19's room, Resident 19's bed control has a crack. The DSD stated Resident 19's bed control was cracked, with rough edges and was visibly dirty. During the same concurrent observation and interview on 1/21/2026 at 12:58 PM with the DSD in Resident 19's room, Resident 19's overhead light has cracks. DSD stated Resident 19's overhead light was cracked. DSD also stated cracks or damaged bed control, and overhead light is not acceptable, and it can cause accident, skin injury, and infection to Resident 19. 5. During a review of Resident 35's admission Record, the admission Record indicated Resident 35 was originally admitted to the facility on [DATE] and was re admitted on [DATE]. The admission record also indicated, Resident 35's diagnoses included diabetes mellitus, hemiplegia (complete paralysis, muscle stiffness, and inability to move one side of the body) and hemiparesis (complete paralysis, muscle stiffness, and inability to move one side of the body). During a review of Resident 35's MDS dated [DATE] the MDS indicated Resident 35 's cognitive skills for daily decision making is moderately impaired. The MDS indicated, Resident 35 was assessed to need substantial/maximaI assistance (helper does more than half the effort. helper lifts or holds trunks or limbs and provides more than half the effort) with eating and oral hygiene. During a review of Resident 35's care plan date initiated on 10/29/2025, the care plan indicated Resident 35 enjoy watching television (news, movies, game shows, music channel) and listening to music. During an interview on 1/20/2026 at 12:18 PM in Resident 35's room, Resident 35 stated the TV in her room was not working. Resident 35 also stated she likes watching TV. During a concurrent observation and interview on 1/21/2026 at 12:27 PM with the Registered Nurse Supervisor (RNS) 1 in Resident 35's room, RNS 1 attempted to turn on the TV and the TV did not turn on. RNS 1 stated the TV was not working and the TV should be working so Resident 35 could use it at any time and enjoy the activity that the resident likes to do. During a concurrent interview and record review on 1/23/2026 at 5:12 PM with the DSD, the facility's Policy and Procedures (P&P) titled Maintenance Services revised date 12/2009, was reviewed. The DSD stated the P&P indicated maintenance services are provided to support a safe, comfortable, and well-maintained environment for residents, staff, and visitors. The P&P also indicated the maintenance department supports the facility by maintaining buildings, grounds, and equipment in safe and proper working condition. The P&P indicated maintenance services are provided in a manner that promotes resident safety, minimizes disruptions, and supports daily operations. The DSD stated the P&P was not followed.

Based on interview and record review, the facility failed to implement the facility's abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) policy regarding investigating an allegation of verbal abuse (the use of oral, written, or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability) for one (1) of two (2) sampled residents (Resident 8) reviewed for abuse.This deficient practice had the potential to compromise or impede the protection of Resident 8, which could affect resident's emotional and mental wellbeing. Cross reference with F610. Findings:During a review of Resident 8's admission Record, the admission Record indicated Resident 8 was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 8's diagnoses included chronic kidney disease (CKD, a condition in which the kidneys are damaged and cannot filter blood as well as they should), anxiety disorder (mental health condition marked by persistent, excessive worry, fear, or nervousness that interferes with daily life), and chronic obstructive pulmonary disease (COPD, a chronic inflammatory lung disease that causes obstructed airflow from the lungs). During a review of Resident 8's Minimum Data Set (MDS, a resident assessment tool), dated 1/12/2026, the MDS indicated Resident 8 had intact cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 8 needed substantial/ maximal assistance (helper does more than half the effort. helper lifts, holds trunk or limbs, and provides more than half the effort) in toileting hygiene, shower/bathe self, lower body dressing, putting on/ taking off footwear, lying to sitting on the side of the bed, and tub/shower transfer. During an interview on 1/20/2026 at 9:26 AM with Resident 8, Resident 8 stated Certified Nursing Assistant 2 (CNA 2) who worked the 3PM to11 PM shift had a bad attitude and was pushy. Resident 8 stated two days ago, on Sunday night, CNA 2 yanked out the drawsheet (are small, durable sheets or absorbent pads placed crosswise over the middle of a resident's bed under a resident's hips and torso to assist with repositioning, transferring, and reducing friction on the skin) under her and threw it on the floor near the door. Resident 8 also stated CNA 2 pulled out her (Resident 8's) brief and grabbed Resident 8's arm and held it straight up while being changed. Resident 8 further stated CNA 2 was mean to Resident 8 and it made the resident cry. Resident 8 stated she informed the Social Services Director (SSD) about CNA 2's bad attitude on 1/19/2026. During an interview on 1/21/2026 at 12:58 PM with Resident 8, Resident 8 stated the incident happened Sunday (1/18/2026) night when CNA 2 grabbed her (Resident 8's) right arm so Resident 8 could not reach the adhesive tabs for her brief as Resident 8 likes to adjust and secure the brief adhesive tabs herself. Resident 8 stated CNA 2 told her to stop and held her arm straight up to prevent her from touching the adhesive tabs. Resident 8 described CNA 2 as rough and scary and that she did not like what CNA 2 did to her and it made Resident 8 cry. During a concurrent interview and record review on 1/21/2026 at 3:35 PM with SSD, the facility's Interview Record dated 1/20/2026 at 3:40 PM was reviewed. The Interview Record indicated Resident 8 recalled CNA during the 3PM-11PM shift and that the resident does not recall the date, and the day of the week that CNA (name not identified in the form) freaked out. The form also indicated Resident 8 requested to be changed and specified she asked CNA to return in 1 hour and CNA refused. The form indicated, when CNA went back to change Resident 8 the CNA roughly took drawsheet (sheet that is placed in such a way that it can be taken from under a patient for various purposes in the healthcare setting such as repositioning) from under Resident 8 and threw it on the floor near the door and when Resident 8 was trying to fasten tabs on her brief, CNA grabbed Resident 8's right arm. The form indicated Resident 8 stated CNA was mean. SSD stated according to the form CNA roughly pulled the drawsheet per Resident 8's interview. During a concurrent interview and record review on 1/21/2026 at 5:11 PM with Director of Health Information (DHI), the Investigation Report dated 1/20/2026 was reviewed. The investigation report was incomplete, and it is missing the name of investigator, name of all the staff being interviewed, name of the Resident that was involved in the allegation and the time the interview was conducted. DHI stated it was the Director of Staff Development (DSD) who provided the copy of the report to the DHI and the DHA knew that there were missing information. During a concurrent interview and record review on 1/21/2026 at 5:21 PM with Administrator (ADM), the Investigation Report dated 1/20/2026 was reviewed. ADM stated the formal investigation report submitted was incomplete and the phone interview conducted by the DSD between the two CNAs (CNA 2 and 3) were missing the CNAs signatures, there was no time indicated when the two CNAs were interviewed and there was no name of the Resident involved in the incident. The ADM stated the DSD concluded in the investigation that CNA 3 was the perpetrator instead of CNA 2. During a concurrent interview and record review on 1/23/2026 11:25 AM with Director of Nursing (DON), the investigation report dated 1/20/2026 was reviewed. The investigation report was incomplete. DSD stated the investigation report was incomplete and confusing, the report had no information if who did the investigation, who was the other CNA, who was the Resident involved and what time the investigation occurred. During a concurrent interview and record review on 1/23/2026 at 11:35 AM with DON, the facility's policy and procedure (P &P) titled, Abuse Investigation and Reporting revised 7/2017 was reviewed. The P&P indicated, the individual conducting the investigation will, as minimum:Review the completed documentation forms.Interview the Resident.Interview the staff members on all shifts who have contact with the Resident during the period of the alleged incident.Review all the events leading up to the alleged incident.The DON stated they did not follow the investigation process per the policy, the documentation interview is inaccurate and incomplete. During a concurrent interview and record review on 1/23/2026 at 12:48 PM with DSD, the undated CNA Statement Form was reviewed. CNA 2's Statement Form was incomplete. DSD stated CNA 2 statement form was missing the interview date, name of interviewer/ investigator, the staff phone number and signature of the staff. DSD stated, CNA 2 statement was not valid because it was incomplete. During a concurrent interview and record review on 1/23/2026 at 1:06 PM with DSD, the facility's P &P titled, Abuse Investigation and Reporting revised 7/2017. DSD stated the investigation process in the policy was not followed because the interviews and/ or investigation report were missing information such as the date and time, resident involve, staff involved, and the interviewer's name. DSD stated it is not considered a valid investigation report if it is of missing all the information needed pet the policy. During a review of the facility's policy and procedure (P&P) titled, Abuse Prevention Program revised 12/2016 was reviewed, the P&P indicated develop and implement policies and procedures to aid the facility in preventing abuse.

Based on interview and record review, the facility failed to follow the process of investigation and report of grievance (a complaint, either oral or written, expressing dissatisfaction with service delivery or the quality of care furnished, regardless of whether remedial action is requested) for one (1) of 15 sampled residents (Resident 8) as indicated in the facility's policy and procedure by failing to document steps taken during the investigation of grievance, summarize pertinent findings or conclusion and document the date the grievance investigation result (decision) was confirmed This deficient practice had the potential to result in miscommunication and inaccurate information of the investigations which did not meet the documentation requirements for Resident 8's grievance.Findings:During a review of Resident 8's admission Record, the admission Record indicated Resident 8 was admitted to the facility on [DATE] and re-admitted on [DATE], Resident 8's diagnoses included chronic kidney disease (CKD, is a condition in which the kidneys are damaged and cannot filter blood as well as they should), anxiety disorder (a disorder characterized by nervousness characterized by a state of excessive uneasiness and apprehension, typically with compulsive behavior [repetitive, persistent, and often uncontrollable actions that a person feels driven to perform] or panic attacks), and chronic obstructive pulmonary disease (COPD, is a chronic inflammatory lung disease that causes obstructed airflow from the lungs) During a review of Resident 8's Minimum Data Set (MDS, a resident assessment tool), dated [DATE], the MDS indicated Resident 8 had intact cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 8 needed substantial/ maximal assistance (helper does more than half the effort. helper lifts, holds trunk or limbs, and provides more than half the effort) in toileting hygiene, shower/bathe self, lower body dressing, putting on/ taking off footwear, lying to sitting on the side of the bed, and tub/shower transfer. During an interview on [DATE] at 3:31 PM with Social Services Director (SSD), the Complaint and Grievance Report (CGR) Form dated [DATE] was reviewed. The CGR Form indicated, during the evening shift (3PM-11PM) care on [DATE] by the unknown Certified Nurse Assistant (CNA), the Unknown CNA pulled sheet from under Resident 8 and threw the sheet on the floor during care. SSD stated, she received the grievance report late morning on [DATE]. SSD stated the incident happened on Sunday during the evening shift, the CNA removed the sheet underneath Resident 8, and the CNA threw it on floor. Resident 8 cannot recall the name of the CNA during the SSD interview and SSD endorsed the report to the Director of Staff Development (DSD). During a concurrent interview and record review on [DATE] at 1:59 PM with SSD, the facility's Complaint and Grievance Report (CGR) Form dated [DATE] was reviewed. There was information missing on the CGR Form:Steps taken to investigate grievanceSummary of pertinent findings or conclusionDate grievance decision was confirmedSSD stated the DSD or nursing department will be the one responsible for the follow-up and ensure the steps taken to investigate the grievance were documented in the CGR. The SSD stated the investigation should have been done by the nursing DSD responsible for a follow-up investigation and the space for the steps taken to investigate grievance including the summary of pertinent findings was left blank which means it was not done. The CGR Form should have included the in-service topic discussed with CNA 3 and it should include a summary of investigation. SSD also stated she did not review the summary and investigation, she should have reviewed and followed up the investigation and completed the CGR Form with the missing information. SSD stated SSD should have completed and explained to Resident 8 the steps that have been taken to investigate the grievance filed. During an interview on [DATE] at 2:06 PM with SSD, SSD stated after conducting thorough investigation on [DATE] of the Grievance report, it was found that it was not CNA 3 who was the staff involved with Resident 8's grievance, it was CNA 2. The investigation and in service was inaccurate for the grievance report for the incident. During a concurrent interview and record review on [DATE] at 2:08 PM with the SSD, the facility's policy and procedure a (P&P) titled, Grievances/ Complaints, Recording and Investigating revised 5/2023, the P&P indicated, upon receiving a grievance and complaint report, the Social Services Director or designee will begin an exploration into the allegations/concerns. SSD stated she could have provided better interviews with Resident 8 and follow up the department responsible for investigating and summary. The Corrective action, my follow- through interview thoroughly and, if she did her follow up interview with Resident 8, she would have captured the grabbing and reported it properly. SSD has to do her own interview as a grievance officer. During a concurrent interview and record review on [DATE] 11:20 AM with the Director of Nursing (DON), the CGR dated [DATE] was reviewed. The CGR Form were missing information on the steps taken to investigate the grievance and summary of pertinent findings or conclusion. The DON stated the space for the steps taken to investigate grievance including the summary of pertinent findings were blank and there was no document attached. The DON stated the investigation report should be attached to the CGR if it was done and if the space for the steps taken to investigate grievance including the summary of pertinent findings was not filled out and there was no attachment, it means it was not done. During a concurrent interview and record review on [DATE] at 11:23 AM with the DON, the facility's policy and procedure (P&P) titled, Grievance revised 7/2017 was reviewed, the P&P indicated, the investigation and report will include, as applicable:a) The date and time of the alleged incident.b) The circumstances surrounding the alleged incident.c) The location of the alleged incident.d) The names of any witnesses and their accounts of the alleged incident.h) Recommendations for corrective action if not already remedied.The DON stated they did not follow the policy because the staff did not fill in the information needed for the CGR form, there was no proof that it was investigated such as letters A to D, and H in the list per the facility's P&P and no information of pertinent findings to draw conclusion. During a concurrent interview and record review on [DATE] at 12:28 PM with DSD, the CGR Form dated [DATE] was reviewed. DSD stated the nursing department was responsible for follow up interview with the resident, and staff involved in the grievance filed and ensured the steps taken to investigate the grievance were documented in the CGRThe DSD stated the space for the steps taken to investigate grievance including the summary of pertinent findings was not filled out and there was no attachment, it means it was not done and the CGR Form for Resident 1 was incomplete they were missing information for the investigation and summary. During a concurrent interview and record review on [DATE] at 12:34 AM with, the facility's policy and procedure (P&P) titled, Grievance revised 7/2017 was reviewed. DSD stated she did not follow the policy because the investigation report that she did for the CGR Form was incomplete, she was missing the names of staff being interviewed, name of the resident involved, time of interviewer, date, names of involved person and name of the interviewer.

Based on observation, interview, and record review, the facility failed to ensure that the call light device (one of the major communication technologies that link nursing home staff to the needs of residents) was within reach (an arm's length) of one (1) of 15 sampled residents (Resident 4). This failure had the potential to cause a delay in care for Resident 4 and prevent the resident from receiving the necessary care and services, which could lead to illness or serious injury.Findings:During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was initially admitted to the facility on [DATE] with diagnosis of dementia (progressive brain disorder that slowly destroys memory and thinking skills), muscle weakness, and aphasia (an impairment of language, affecting the production or comprehension of speech and the ability to read or write). During a review of Resident 4's Minimum Data Set (MDS, a resident assessment tool), dated 12/10/2025, the MDS indicated Resident 4's cognitive skills (processes of thinking and reasoning) for daily decision making was severely impaired (never/rarely made decisions). The MDS also indicated Resident 4 was partial/moderate assistance (helper does less than half the effort) on personal hygiene (the ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face and hands (excluding baths, showers, and oral hygiene). The MDS indicated Resident 4 was dependent (helper does all the effort, resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity) on toileting hygiene (the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement). During a review of Resident 4's care plan revised on 12/18/2025, the care plan indicated Resident 4 was at risk for fall related to confusion, history of fall, incontinence (involuntary loss of urine or stool), unaware of safety needs, poor vision. The care plan also indicated to ensure the resident's call light is within reach and encourage the resident to use it for assistance as needed. During a review of Resident 4's care plan initiated on 5/28/2025, it indicated Resident 4 cannot verbally communicate which makes having the call light at his (Resident 4) side very important as well as paying attention to his verbal cues. The care plan indicated the activities will trigger call light and alert nursing staff at Resident 4's request for medications and pain management. During an observation on 1/20/2026 at 2:24 PM in Resident 4's room, observed Resident 4 call light coiled on the right of the resident's bed rails (are adjustable metal or rigid plastic bars that attach to the bed. They are available in a variety of types, shapes, and sizes ranging from full to one-half, one-quarter, or one-eighth lengths) and hanging, the call was visibly out of Resident 4's reach. During a concurrent observation and interview on 1/22/2026 at 7:58 AM in Resident 4's room with the Certified Nursing Assistant (CNA1), observed Resident 4 looking for his call light. CNA 1 stated the call light was observed coiled at the resident's bed rails hanging down. CNA 1 stated the resident was looking for the call light and was unable to find and reach it. CNA 1 stated call lights should be easily accessible. During an interview on 1/23/2026 5:07 PM with the License Vocational Nurse (LVN 1), LVN 1 stated the call light should be answered as soon as possible and the call light should be placed within the resident's reach. LVN 1 stated the call light was the resident's way of communication, and to alert the facility staff when the resident needs assistance. LVN 1 stated Resident 4 can feel hopeless and that nobody cares for the resident, and that is why it is very important to ensure call light is within the resident's reach at all times. During a review of facility's Policy and Procedure (P&P) titled Answering the Call Light revised 9/ 2022, it indicated the purpose of policy and procedure is to ensure timely responses to the resident's requests and needs. The P&P also indicated ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor.

Based on interview and record review, the facility failed to report an allegation of verbal abuse (the use of oral, written, or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability) for one (1) of two sampled residents (Resident 8) reviewed for abuse, within 2-hour timeframe to the State Survey Agency (SA, where state law provides for jurisdiction in long-term care facilities), the state ombudsman (advocates for residents of nursing homes, board and care homes and assisted living facilities), and local law enforcement. This deficient practice had the potential to compromise or impede the protection of Resident 8, which could affect resident's emotional and mental wellbeing. Findings:During a review of Resident 8's admission Record, the admission Record indicated Resident 8 was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 8's diagnoses included chronic kidney disease (CKD, a condition in which the kidneys are damaged and cannot filter blood as well as they should), anxiety disorder (mental health condition marked by persistent, excessive worry, fear, or nervousness that interferes with daily life), and chronic obstructive pulmonary disease (COPD, a chronic inflammatory lung disease that causes obstructed airflow from the lungs) During a review of Resident 8's Minimum Data Set (MDS, a resident assessment tool), dated 1/12/2026, the MDS indicated Resident 8 had intact cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 8 needed substantial/ maximal assistance (helper does more than half the effort. helper lifts, holds trunk or limbs, and provides more than half the effort) in toileting hygiene, shower/bathe self, lower body dressing, putting on/ taking off footwear, lying to sitting on the side of the bed, and tub/shower transfer. During an interview on 1/20/2026 at 9:26 AM with Resident 8,Resident 8 stated Certified Nursing Assistant 2 (CNA 2), who worked the 3 PM to 11 PM shift, had a bad attitude and was pushy. Resident 8 stated that two days ago, on Sunday night, CNA 2 yanked out the drawsheet (a small, durable sheet or absorbent pad placed crosswise over the middle of a resident's bed under the hips and torso to assist with repositioning, transferring, and reducing friction on the skin) from under her and threw it on the floor near the door. Resident 8 stated CNA 2 then pulled out her brief and grabbed her arm, holding it straight up while changing her. Resident 8 further stated that CNA 2 was mean and made her cry. Resident 8 stated she reported the incident to the Social Services Director (SSD) on 1/19/2026. During an interview on 1/20/2026 at 3:38 PM with SSD, SSD stated Resident 8 reported on 1/19/2026 that a CNA from the 3 PM to 11 PM shift had pulled the sheet from under Resident 8 and thrown the drawsheet onto the floor. During an interview on 1/21/2026 at 12:58 PM with Resident 8, Resident 8 stated police officers came to speak with her regarding the allegation of abuse. Resident 8 stated the incident occurred on Sunday night (1/18/2026). Resident 8 stated CNA 2 grabbed her right arm so she could not reach the adhesive tabs for her brief, as Resident 8 likes to adjust and secure the tabs herself. Resident 8 stated CNA 2 told her to stop and held her right arm straight up to prevent her from touching the tabs. Resident 8 described CNA 2 as rough and scary, stating CNA 2 made her cry and that she did not like what CNA 2 did to her. During a concurrent interview and record review on 1/21/2026 at 4:23 PM with Registered Nurse Supervisor 2 (RNS 2), the RN Statement/Witness Report (RSWR), dated 1/20/2026 was reviewed. The RSWR indicated on Sunday, 1/18/2026, RNS 2 was walking in the hallway when she heard Resident 8's voice coming from her room. RNS 2 entered the room and observed that both Resident 8 and CNA 2 were upset. Resident 8 informed RNS 2 that the drawsheet had been thrown on the floor. Resident 8 remained upset even after RNS 2 placed another drawsheet under her because the previous drawsheet had been thrown on the floor. RNS 2 stated that during the 3 PM to 11 PM shift on Sunday, she heard loud voices from Resident 8's room. Resident 8 stated that CNA 2 threw the drawsheet on the floor and became upset. Resident 8 likes to have two drawsheets and stated that she told CNA 2 what she wanted, but CNA 2 was not listening. Resident 8 refused further care from CNA 2, and her voice was shaky. RNS 2 stated that she got overwhelmed and busy with her shift and should have reported the incident to the Administrator or Director of Nursing (DON) because it was a possible allegation of abuse. RNS 2 stated she should have endorsed it to the other licensed nurse. During an interview on 1/21/2026 at 4:43 PM with CNA 2, CNA 2 stated Resident 8 requested two drawsheets because one of her drawsheets was dirty. CNA 2 stated that Resident 8 insisted on having two drawsheets. CNA 2 removed one drawsheet and left the room. CNA 2 stated RNS 2 was in the hallway and asked her to come into Resident 8's room. CNA 2 stated Resident 8 was yelling that CNA 2 was rough and rude to her and was upset with CNA 2. During an interview on 1/22/2026 at 2:11 PM with SSD, SSD stated that she should have conducted a thorough investigation of Resident 8's reported incident and could have reported it immediately. SSD stated it was important to report and notify the appropriate agencies to prevent further incidents of abuse and ensure Resident 8's safety. During a concurrent interview and record review on 1/23/2026 at 11:26 AM with the Director of Nursing (DON), the investigation report dated 1/20/2026 was reviewed. The report indicated CNA 3 stated Resident 8 told her that the CNA who took over her care last Sunday, 1/18/2026, after 7 PM was rude to her. The DON stated CNA 3 should have reported this to the DON, the charge nurse, or the Director of Staff Development (DSD) when Resident 8 reported that the staff was mean. The DON stated CNAs are mandated reporters and should have reported the allegation to the Administrator, DON, Director of Staff Development (DSD), and SSD within two hours During a concurrent interview and record review on 1/23/2026 at 11:50 AM with DON, the facility's policy and procedure (P &P) titled, Abuse Investigation and Reporting revised 7/2017 was reviewed. The P&P indicated, an alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than:Two (2) hours if the alleged violation involves abuse or has resulted in serious bodily injury.DON stated the staff should have called within 2 hours because of the allegation of abuse. Resident 8 mentioned to CNA 3 that the other staff was rude, which is possible verbal abuse. We should report immediately to prevent abuse to Resident 8, and we should make sure the residents are protected from abuse. During a review of the facility's policy and procedure (P&P) titled, Abuse Prevention Program revised 12/2016 was reviewed, The P&P indicated, Investigate and report any allegations of abuse within timeframe required by federal requirements.

Based on observation, interview and record review the facility failed to maintain an effective pest control program in the facility and failed to prevent mosquito bites affecting three out of three sampled residents (Resident 1, Resident 2, and Resident 3) in accordance with facility ' s policy and procedure. These deficient practices had the potential to result to serious illness and has the potential to affect all 33 residents if the mosquitoes were able to enter and bite the residents in the facility. Findings: During a concurrent observation and interview on 8/9/2022 at 1:07 PM, with Resident 3 in the Rehabilitation Room, Resident 3 was observed to have a mosquito bite on the right forearm (approximately 1.5 centimeters in diameter) and two mosquito bites on the left upper arm (less than 1 centimeter in diameter). Resident 3 stated, he was bitten by mosquitoes on his bilateral arms. Resident 3 has seen mosquitoes in the facility. The mosquitoes came from the settled water out on the curb near the patio area. During interview with Resident 1 on 8/9/2022 at 1:18 PM, Resident 1 stated, I have seen mosquitoes in the facility. I have an Off Mosquito Lotion sent by my daughter. We have mosquitoes for couple of months now. I was bitten all over my body when I fall asleep. A lot of residents and CNAs got bitten too. During an observation 8/9/2022 at 1:24 PM, inside Resident 1 ' s Room, there was one mosquito flying around Resident 1 and landed on her bedside table and then flew towards the window behind Resident 1 ' s bed. During an observation on 8/9/2022 at 1:26 PM, inside Resident 1 ' s Room , there were two dead mosquitoes left stuck on Resident 1 ' s bedroom walls. During an observation on 8/9/2022 at 1:31 PM, inside Resident 1 ' s restroom, there was a gap in between the window frame and the window screen frame. During an interview with Licensed Vocational Nurse 1 (LVN 1) on 8/9/2022 at 1:48 PM, LVN 1 stated, Residents have complained about the mosquito bites two months ago. During an interview with Director of Environmental Services (DEVS) on 8/9/2022 at 1:48 PM, DEVS stated, I have seen mosquitoes in the facility this month. It ' s been ongoing for two years. During an interview with Certified Nursing Assistant 3 (CNA 3) on 8/9/2022 at 2:03 PM, CNA 3 stated, I have seen mosquitos bites on the residents. It ' s been about a month now. One resident had a lot of bites. I see them on the walls and try to kill them, but they fly away. I have been bitten. During an interview with Administrator (ADM) on 8/9/2022 at 2:21 PM, ADM stated, we have seen mosquitoes in the facility. Mosquito is seasonal, so we just added that to our contract. Usually, it ' s just regular pest control. The trees have mosquitoes. During a concurrent observation and interview on 8/9/2022 at 3:03 PM, with LVN 2, inside Resident 2 ' s Room, Resident 2 was observed to have multiple mosquito bites on her bilateral lower extremities. During an interview with Resident 3 on 8/9/2022 at 3:22 PM, Resident 3 stated, He informed LVN 6 about his mosquito bites a few weeks ago. No treatment provided to Resident 3 ' s mosquito bites. Resident 3 left the facility to get Off Bug Spray from the drugs store down the street few weeks ago. During an interview with Resident 2 on 8/9/2022 at 3:44 PM, Resident 2 stated, I did not tell the staff about the mosquito bites. Why bother, they will not do anything anyway. During an interview with LVN 6 on 8/9/2022 at 3:47 PM, LVN 6 stated, Resident 3 had informed him about itchy mosquito bites on his arm a few weeks ago. LVN 6 stated he informed the Registered Nurse Supervisor (RN Supervisor) that evening. LVN 6 stated that he did not follow up with the RN Supervisor. During interview with Resident 1 on 8/9/2022 at 3:51 PM, Resident 1 stated, I have been bitten by mosquitoes on and off. Resident 1 complained about the mosquito bites to the CNA few weeks ago. None was done, no assessment from the treatment nurse. During an interview with Assistant Administrator (AADM) on 8/9/2022 at 3:51 PM, AADM stated, we were aware of having mosquitoes in the facility, but we were not aware about the mosquito bites of Resident 1. A record review of Orkin Pest Control Service Ticket # 2696 dated 7/25/2022 at 6:26PM, indicated on the general comments- Live mosquitoes were found throughout exterior perimeter where mosquito traps have been found. A record review of Orkin Pest Control Service Ticket # 2696 dated 7/25/2022 at 7:21 PM, indicated on Pest Activity: Zone- Interior, Pest Finding- Mosquitoes, Pest Count 20. A review of the facility's policy and procedure titled Pest Control, revised May 2008, indicated on the policy interpretation and implementation, this facility maintains an ongoing pest control program to ensure that the building is kept free of insects and rodents. A review of the facility's policy and procedure titled, Quality of life- Homelike Environment , revised May 2017, indicated on the policy statement, Resident are provided with a safe, clean, comfortable and homelike environment.

Based on observation, interview, and record review, the facility failed to prevent the infestation of cockroaches (small insects that cause spread of bacterial infection) in the facility's kitchen, where foods were prepared and served, for the 31 residents in the facility by failing to: 1. Maintain an effective pest control program. 2. Close any cracks or crevices in the kitchen where cockroaches could enter. As a result, the facility's kitchen was closed on 2/25/20 and placed the 31 residents at risk for vector-borne diseases (diseases that result from an infection transmitted to human by insects such as cockroaches). Findings: On 2/25/20 at 10:00 a.m., the Los Angeles County Department of Public Health Environmental Health Services Inspector ((EHS) performs inspections of various licensed health care facilities and properties to determine conformance with applicable State laws and County Ordinance Code sections) notified California Department of Public Health (CDPH) regarding closure of the facility's kitchen due to active infestation of egg caseins (egg based protein) and live nymph (baby), juvenile, and adult German cockroaches in the facility's kitchen areas. On 2/25/20 at 1:22 p.m., an unannounced visit was conducted to investigate the reported active infestation of cockroaches in the facility's kitchen. A review of the Los Angeles County Department of Public Health Environmental Health Services Retail Food Inspection Report, dated 2/25/20, indicated cockroaches were found in the facility's kitchen areas. These areas included: one live juvenile German cockroach on the floor in the utensils storage room adjacent to the kitchen; three live adult, one live nymph, and one egg casein German cockroaches on the wall above a window in an employee storage room located in between the dry food storage room and water heater closet; one egg casein on the floor by the water heater closet door in the short hallway; and one egg casein on the floor in the water heater closet. The inspector additionally observed: one dead adult German cockroach on the floor in the utensils storage room adjacent to the kitchen; two dead adult German cockroaches on the floor by the water heater closet door in the short hallway; three dead adult German cockroaches on the floor in the water heater closet; one dead adult German cockroach on the floor in the dry food storage room; one dead adult German cockroach on the floor by the kitchen door leading to the short hallway in the kitchen; and five dead adult German cockroaches on the floor by the mop sink area (laundry area). Fecal spotting was also observed on the wall in an employee storage room located in between the dry food storage room and water heater closet and on the wall above the water heater closet door in the short hallway. The facility's kitchen was closed. A review of the facility's census report, dated 2/25/20, indicated there were 31 residents residing in the facility. During the kitchen observation, on 2/25/20 at 1:41 p.m., cracks and crevices were observed in the staff room next to the kitchen. Three live German roaches, fecal spotting, one live baby, one egg casings were observed in the staff room next to the kitchen. In the hallway next to the kitchen, two dead German roaches and one egg casing were observed. Five dead German roaches were observed behind the water heater. In the dry storage area, one dead German roach was observed. In the utensil storage room, one live German roach and one dead German roach were observed. Five dead German roaches were observed in the mop sink room. A review of the Pest Control Company's Contract, initiated 2/17/20, indicated the company would provide service for roaches, common ants, rats and mice, one time per month. A review of the facility's Pest Control Company's Service Report, dated 2/19/20 and timed at 7:44 p.m., indicated 20 live German roaches were observed in the facility's basement level. During an interview with the Dietary Supervisor (DS) on 2/25/20 at 2:20 pm, the DS stated the new pest control company came the week before. The DS stated the pest control company was changed last month and they had difficulty contacting the previous pest control company. A review of the facility's Pest Control Company's Service Report, dated 2/25/20 and timed at 5:18 p.m., indicated their recommendation was to repair all structural damage to ensure that pests could not nest in those areas. During an interview with a dietary aide (DA) on 2/26/20 at 8:45 am, DA stated she saw roaches in the kitchen once in a while. The DA stated one time she was sweeping the kitchen and saw one or two live roaches, but did not indicate the date when. The DA stated she informed DS. During an interview with a dietary cook (DC) on 2/26/20 at 8:51 am, the DC stated she saw a cockroach in the kitchen last Saturday, she killed it, and placed it in the trash. The DC wrote it in the logbook and informed the DS. During an interview with the housekeeping supervisor (HS) on 2/26/20 at 11:00 am, the HS stated she saw one live cockroach in the kitchen and informed the DS. During an interview with the Maintenance Supervisor (MS) on 2/26/20 at 11:12 am, the MS stated he saw roaches in the employee lounge and the kitchen. The MS stated he saw one live and one dead cockroach in the employee lounge two weeks ago and one live cockroach in the walkway to the kitchen. The MS stated he killed them, placed them in the dustpan, and called the exterminator. During a concurrent observation and interview with the MS on 2/26/20 at 11:16 a.m., an opening in the wall in the laundry room area next to the kitchen was observed. The MS stated he would patch the opening in the wall. During an interview with the DON on 3/3/20 at 1:45 p.m., the DON stated if there is a roach infestation in the kitchen, infection issues could arise due to where roaches travel, and they carry it to the food. The DON stated the food that residents eat is prepared in the kitchen and might give the residents diarrhea, possible abdominal pain, and might cause them to vomit. A review of an undated article titled, Effective Management of Cockroach Infestations by the County of Los Angeles Vector Management Program, (Retrieved 3/3/20 at http://publichealth.lacounty.gov/eh/docs/Specialized/Vector_Management/cockroachMgmt.pdf) the German cockroach is the most common of the cockroach species. The article indicated that cockroaches may become pests in any structure that has food preparation or storage areas. They contaminate food and eating utensils, occasionally damage fabric and paper products, leave stains on surfaces, and produce unpleasant odors when present in high enough numbers. When cockroaches that live outdoors come into contact with human excrement in sewers or with pet droppings, they have the potential to transmit bacteria that cause food poisoning if they enter into structures and are believed to be capable of transmitting diseases. Generally, for every cockroach seen in the daytime there are many more concealed in dark, protected locations. A review of undated information provided on Orkin's (pest control company) website, titled, German Cockroach Diseases, (Retrieved 3/3/20 from https://www.orkin.com/cockroaches/german-cockroach/diseases) indicated almost everybody part of a German cockroach can carry harmful bacteria. For example, Salmonella (illness caused by contaminated food or water) and E. coli (illness caused by contaminated food or water) on the pests' bodies may cause food poisoning and dysentery (infection of the intestines resulting in severe diarrhea with the presence of blood and mucus in the feces). Even a single touch may be enough to transfer disease causing organisms onto food and surfaces. Cockroach fecal wastes, cast skins, and saliva may also cause allergic reactions. Symptoms include rashes and breathing issues. A review of the facility's policy and procedure on Pest Control, revised date 8/11, indicated the facility safely guarded against any pest, rodents, and any other forms of infectious living insect/animals. The facility surrounding areas will be kept clean at all times, and gaps in the door or even in the wall of the facility will be repaired immediately by the maintenance supervisor. A review of the facility's policy titled, Maintenance Service with a revision date 12/09, indicated the Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.

Based on observation, interview, and record review, the facility failed to ensure one of 10 sampled residents (Resident 5), who was admitted to the facility with no pressure sores and was assessed as high risk to develop pressure sores, was provided necessary treatment and services for prevention of and to promote healing of pressure sores by failing to: 1. Provide turning and repositioning every 2 hours as needed and as indicated in the plan of care to prevent a pressure sore from developing. 2. Monitor for new skin breakdowns and redness, (Stage I or II pressure sores) 3. Report to the physician when a Stage I/II pressure sore developed and obtain treatment orders so as to prevent the resident ' s pressure sore progression. These deficient practices resulted in Resident 5 developing an avoidable Stage III pressure sore. Findings: During the initial tour of the facility on June 4, 2015 at 5:45 p.m., Resident 5 was observed lying flat in his bed. During observations on June 5, 2015 at 4:35 p.m., June 6, 2015 at 7:30 a.m., 9 a.m. and 11 a.m., 1 p.m. and 3 p.m., and on June 7, 2015 at 7:30 a.m., 9:30 a.m. and 11:30 a.m., the resident was observed lying flat on his back. During an interview with Resident 5 and his family member on June 7, 2015, at 12:15 p.m. Resident 5 stated staff did not turn and reposition him every 2 hours. The family member stated on the previous Thursday (June 4, 2015) at lunchtime, she turned on the call light to get help to reposition Resident 5 in his bed. She stated after 20 minutes she walked out into the hallway to look for someone to help her. She stated the person in charge told her that her nurse was busy with another resident and would help her as soon as she was free. She did not remember who it was. At that time, Family Member 1 stated Resident 5 had a sore on his back. On June 7, 2015, at 12:30 p.m., during an observation with LVN 1, she confirmed Resident 5 had a Stage III pressure sore that was not identified previously. On June 7, 2015, at 12:35 p.m., during an interview with LVN 1, who was assigned to Resident 5, she stated she had not yet assessed Resident 5 during her shift. At the same time, CNA 1 who was present at the resident's bedside stated he had not noticed any skin breakdown on the resident's back. According to the Nursing Care Ready Reference: Resident Assessment Protocols, Page 61, residents who have an existing pressure sore should have all pressure eliminated to the sore area, pressure for even a few minutes is too long. Review of the admission information sheet indicated Resident 5 was readmitted to the skilled nursing facility (SNF) on April 8, 2015 with [DIAGNOSES REDACTED]. Diabetes is associated with prolonged, impaired wound healing. Risk factors emerging most frequently as independent predictors of pressure ulcer development included three primary domains of mobility/activity, perfusion (including diabetes) and skin/pressure ulcer status, Internet PubMed,US National Library of Medicine <http://www.nlm.nih.gov/> National Institutes of Health <http://www.nih.gov/>. The Minimum Data Set (MDS, an assessment and screening tool) dated April 15, 2015 indicated Resident 5's cognitive skills for daily decision-making were fully intact, he had impaired range of motion to all extremities, and was totally dependent on staff assistance for all activities of daily living. The resident had an indwelling urinary drainage tube and had no pressure sores /skin problems. The Nursing Admission assessment dated [DATE] indicated Resident 5 had an old scar in the area near his tailbone. According to the Centers for Medicare and Medicaid State Operation Manual for Pressure Sores 483.25 ( c ), tissue closest to the bone may be the first to undergo necrosis (the death of living cells or tissues), including the sacrum (tailbone). The resident's current skin status was described as dry and warm, no redness or [MEDICAL CONDITION] noted. Review of the physician's admitting orders dated April 8, 2015 indicated an alternating pressure mattress for skin management, skin breakdown prevention, and pressure sore prevention. There was no documented evidence for May or June 2015, of any current skin treatments being provided, for the prevention of or to promote healing of pressure sores. Review of Resident 5 ' s care plan titled Risk For Skin Breakdown Related to Immobility and Incontinence of Bowel and Bladder initiated April 8, 2015, included the interventions of turning and repositioning at least every 2 hours and as needed, monitoring and reporting new skin breaks and redness, and provide good skin care daily and after each incontinence. A care plan titled At Risk For Discomfort and Pain initiated April 8, 2015 included interventions to monitor for areas of redness, swelling, pain, inflammation, open areas, change in functioning, and to notify the physician. The care plan was not updated to address Resident 5 ' s Stage III pressure sore. Review of Licensed Personnel Progress Notes from April 28, 2015 to June 7, 2015 indicated no documentation of skin problems for Resident 5. Review of a Braden Scale for Predicting Pressure Sore Risk assessment dated [DATE], indicated a total score of 13, which indicated Resident 5 was a high risk for development of pressure sores. Review of certified nurse aide (CNA) care record forms of Resident 5's activities of daily living from June 1 to June 6, 2015, indicated only the level of assistance the resident required, but did not track how often or at what times Resident 5 was turned, toileted, or cleaned. This was verified in an interview with the Director of Nursing on June 10, 2015 at 10 a.m. Review of Daily Body Check Reports completed by the assigned C N A ' s including C N A 1, reviewed by the assigned licensed nurse, including LVN 1, and the director of nurses (DON), dated May 29, 2015, to June 6, 2015, all indicated Resident 5's skin was OK. During an interview with the DON on June 7, 2015 at 4 p.m., she stated she had signed off on the Daily Body Check Reports, but she was not aware Resident 5 had a pressure sore. There was no documented evidence in the clinical record that the facility provided turning and repositioning every 2 hours as indicated in the plan of care, to prevent Resident 5 from developing a Stage III pressure sore. There was no documented evidence in the clinical record that the facility monitored Resident 5 for and reported new skin breakdowns and redness, (Stage I or II pressure sore) and obtained treatment orders, until Resident 5 ' s pressure sore progressed to a Stage III. Once a pressure sore has developed, interventions should be initiated based on the characteristics of the sore e.g., stage, size, location, amount of exudate, type of wound, presence of infection or pain and the resident ' s general status, Medical-Surgical Nursing, Lewis,Dirksen,Heitkemper,Bucher, Ninth Edition, page 186. On June 7, 2015 at 2:05 pm the facility staff notified the physician of the resident ' s Stage III pressure sore that measured 3 centimeters (cm) X 1 cm on the tailbone area. The physician ordered the following treatment: Cleanse open sore on the coccyx (tailbone) area with normal saline (salt water), pat dry, apply calcium alginate dressing then cover with duoderm and change every seven days and when needed, for dislodged or soiled dressing. The facility's policy and procedure titled Daily Body Check Report undated indicated it is the facility policy to check the resident ' s body daily to detect any skin problem. The CNA is responsible to indicate all problems found on the patient and document on the report. The LVN is responsible to conduct complete body check on all problem areas noted, report new findings to physician, and document changes in patient's chart. The DON is responsible to review findings and ensure that appropriate action is taken. The facility's policy and procedure titled Management of at Risk Patients undated, indicated for patients at risk for skin impairment: inspect skin every week, reposition every 2 hours.

Based on observations, clinical record review, review of facility policy and procedure and staff interviews, the facility failed to ensure that one sampled resident (Resident #6) maintained his body weight. The facility also failed to properly assess the nutritional needs and identified problems. In addition, they failed to follow the physician ' s tube feeding order. These failures resulted in a severe weight loss of 14.5 pounds or 11% of his body weight. Findings: 1. A review of Resident 6's clinical record conducted on 8/6/11, indicated that the resident was initially admitted to the SNF facility on 2/14/11, and readmitted on [DATE], with [DIAGNOSES REDACTED]. The Quarterly MDS (Minimum Data Set, a resident assessment tool) dated 7/23/11, indicated that the resident's cognitive status was severely impaired (unable to make decisions for himself), and was totally dependent on staff for all daily living needs. The resident was aphasic (unable to speak due to stroke) but was alert. Resident 6 was 5' 4" and 132 lbs on admission. His physician ordered diet was a pureed NAS (no added salt). The nutritional assessment form also indicated the resident had a tendency to hold his food in his mouth. There were no recommendations or interventions made for this identified problem or evaluation of the resident ' s nutritional needs. A review of the Monthly Record of Vital Signs and Weights indicated the following: Date Weight 2/14/11 132 lb. (Admission) 3/3/11 132 lb, 4/2/11 126.5 lb (loss of 5.5 lb in one month) 5/12/11 124 lb (loss of 2.5 lb) 6/8/11 121.5 lb (loss of 2.5 lb) 7/12/11 117.5 lb (loss of 4 lb) The RD assessment did not include the estimated calories and the protein required to meet the resident's needs. There was a physician order [REDACTED]. The resident's weight on 4/2/11 was 126.5 lb. This is a loss of 5.5 lb or 4.1% in one month). A care plan was developed on 4/21/11. Documentation indicated that the physician was aware of the weight loss and no new orders were given. The care plan approaches included to monitor intake, record and report intake that fell below 70%. On 5/12/11, the resident weighed 124 lbs, He had further lost 2.5 lbs in a month, a total of 8 lbs since admission or 6% of his total weight. This was a significant weight loss. A quarterly assessment dated [DATE], documented by the DSS, indicated that the resident's weight was 124 lb, which reflected a difference of eight lb for that quarter. The DSS recommended the same diet as ordered in March and plan to continue to monitor the resident. There was no evidence of an RD assessment for May 2011, for the resident. There were no new interventions. The resident's weight on 6/8/11, was 121.5 lbs. Resident 6 had lost an additional 2.5 lbs in one month, and a total loss of 10.5 lbs since admission. This is a severe weight loss of 7.9% in three months. A review of the CNA logs for June 2011, indicated that the resident's meal intake was between 60-80% consumed. The facility failed to follow Resident 6's care plan. The care plan intervention dated 4/12/11, indicated to report if intake fell below 70%. The care plan approaches included to monitor intake, record and report intake that fell below 70%. There was no documented evidence that the facility reported when intake fell below 70%. There was physician's orders [REDACTED]. The IDT meeting dated 7/8/11, indicated there was a care plan meeting with the resident's family member on the issue of weight loss. A recommendation was made for the resident to have a registered dietitian (RD) assessment, and to monitor weight status. There was a physician order [REDACTED].i.d. (twice daily) between meals. This order for weekly weight was not carried out. The RD made a entry on the nutritional progress notes of 7/12/11, recommending to change the resident's diet to a large portion fortified pureed NAS (no added salt) NCS (no concentrated sweets) diet with extra sauce/gravy. There was a physician order [REDACTED]. On 7/12/11, the resident weighed 117.5 lbs. This was an additional 4.5 lb weight loss for the month; 14.5 lbs since admission or 11% total weight loss in four months. This is considered a severe weight loss. The review of RD progress notes dated 7/20/11 revealed to conduct a calorie count for three days, and to obtain laboratory tests (sodium, potassium, BUN-blood urea nitrogen, H&H-hematocrit and hemoglobin) for evaluation. (laboratory tests are used to determine the resident's nutritional status). The physician order [REDACTED]. The facility initiated the calorie count and did the laboratory tests as the physician ordered. There was no evidence that weekly weight monitoring had been provided to the resident in July 2011. On 8/6/11 at 4:40 p.m., during an interview and record review, the DSS confirmed the resident was not placed on a nutritional supplement until July 2011. The DSS stated she thought she spoke with the RD in June 2011, and stated ... "I don't know what happened." The DSS also indicated she was unable to recall if weekly weights were carried out. On 8/6/11 at 5 p.m., during an interview and review of the clinical record, the director of nurses (DON) was unable to locate any documented evidence that the physician had been notified on 4/2/11 of the resident's 5.5 pound weight loss. (there was indication earlier that the MD was notified) The DON could not explain why weekly weights were not done for Resident 6 in spite of having already experienced a weight loss of approximately 11% over a four month period. During an interview with CNA 2 on 8/7/11 at 3:15 p.m., she indicated that the resident's appetite had declined 1-2 months prior to his admission to the general acute care hospital on July 23, 2011. During an interview with CNA 3 on 8/7/11 at 3:50 p.m. she stated that the resident's appetite started to decline in May. The facility did not implement any interventions for weight loss until 7/8/11. There was no evidence to indicate the CNA 2 or 3 had reported the resident's decline in meal intake percentage to the licensed nurse. A review of the facility's undated policy titled "Follow-up on Significant Weight Loss ...stipulated the DSS would ... note resident's weight loss ... for the R.D. to assess on the next visit. There was no evidence in the clinical record that this policy was followed. The licensed personnel progress notes of 7/23/11, indicated that Resident 6 was to be transferred to an acute care hospital for further evaluation and the resident was difficult to arouse. The physician orders [REDACTED]. Then maintain 60 ml /hr of Glucerna. Resident 6 was not receiving anything by mouth. The care plan approach for having a GT dated 7/28/11, indicated that the resident would have the tube feeding as ordered. As indicated by the physician's orders [REDACTED]. On 8/5/11 at 6:30 p.m., and 8/6/11 at 8:15 a.m., Resident 6 was observed lying in bed. A tube feeding formula was infusing via a gastrostomy tube at a rate of 40 ml per hour via an enteral feeding pump. On 8/6/11, a review conducted of Resident 6's clinical record indicated that the resident had been readmitted to the SNF from the general acute care hospital on [DATE], and a gastrostomy tube had been inserted into the resident's stomach for nutritional purposes during the resident's hospital stay. On 8/6/11 at 2:15 p.m., during observation and interview, the 7 a.m. to 3 p.m. charge nurse stated she had noted the physician admitting orders on 7/28/11, and the tube feeding rate should be 60 ml per hour. After the surveyor asked about the resident's GTF, the charge nurse increased the GTF rate from 40 ml to 60 ml per hour. The resident had already experienced a recent severe weight loss of more than 10% over a four month period from 3/3/11, when the resident weighed 132 lb, to 7/8/11, when the resident weighed 117.5 lb. The facility failed to follow the physician's orders [REDACTED]. There were no interventions when problems of pocketing of food, or the initial weight loss was identified, there was no proper nutrition assessment completed, they failed to implement care plan strategies, and did not provide Resident 6 with adequate nutrition.